{
  "hospital_name": "610920842 - The Medical Center at Bowling Green",
  "last_updated_on": "2026-04-01",
  "version": "3.0.0",
  "location_name": [
    "The Medical Center at Bowling Green"
  ],
  "type_2_npi": [
    "1043293608", "1588797260", "1043293608"
  ],
  "hospital_address": [
    "250 Park St. Bowling Green, KY 42101"
  ],
  "license_information": {
    "license_number": "100404",
    "state": "KY"
  },
  "attestation": {
    "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.",
    "confirm_attestation": true,
    "attester_name": "Michele Lawless"
  },
  "standard_charge_information": [
    {
      "description": "CONTROLLER-AZUR DETACH 45-4001",
      "code_information": [
        {
          "code": "1411129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FUNNEL-KELLER 2 HA-005",
      "code_information": [
        {
          "code": "3000004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 3FR 0   390-103",
      "code_information": [
        {
          "code": "3002153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-STONE 1.9FR     390-105",
      "code_information": [
        {
          "code": "3002162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-1.3F NITINOL STONE",
      "code_information": [
        {
          "code": "3002170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIPOFILTER-ASP CAN 25",
      "code_information": [
        {
          "code": "3002211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 2.0",
      "code_information": [
        {
          "code": "3002254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLUTED 4.0MM  315.40",
      "code_information": [
        {
          "code": "3002335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0          357.407",
      "code_information": [
        {
          "code": "3002356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TIB DRILL 195MM     315.29",
      "code_information": [
        {
          "code": "3002367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 PERIPH SCREW",
      "code_information": [
        {
          "code": "3002369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM     03.617.9xx",
      "code_information": [
        {
          "code": "3002371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5",
      "code_information": [
        {
          "code": "3002374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X230   1806-35xxS",
      "code_information": [
        {
          "code": "3002378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        72-2011",
      "code_information": [
        {
          "code": "3002384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 324.214",
      "code_information": [
        {
          "code": "3002392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM 702453",
      "code_information": [
        {
          "code": "3002396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8737-09",
      "code_information": [
        {
          "code": "3002398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 255589000",
      "code_information": [
        {
          "code": "3002401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.0 SCREW DRIVER",
      "code_information": [
        {
          "code": "3002656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1xMM 2868-20-01x",
      "code_information": [
        {
          "code": "3002771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              316.286",
      "code_information": [
        {
          "code": "3002781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SIZES     703xxx",
      "code_information": [
        {
          "code": "3002789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT ALL    18-84004HR",
      "code_information": [
        {
          "code": "3003228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT 2.9MM    18-82904",
      "code_information": [
        {
          "code": "3003237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER     62-27015",
      "code_information": [
        {
          "code": "3003253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO              CYB-x",
      "code_information": [
        {
          "code": "3003505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION xMM 5820-009-0xx",
      "code_information": [
        {
          "code": "3003845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 29FR 96370-029",
      "code_information": [
        {
          "code": "3004237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 10M OMS-T10BT",
      "code_information": [
        {
          "code": "3005080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-OMEGA        1004930",
      "code_information": [
        {
          "code": "3009748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ENDO LINEAR       ATS45",
      "code_information": [
        {
          "code": "3009970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACCESS 10 GAUGE",
      "code_information": [
        {
          "code": "3012102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SKYLINE 14MM   286820014",
      "code_information": [
        {
          "code": "3012132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SZ   2883-01-xxx",
      "code_information": [
        {
          "code": "3012205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-PERCUTANEOUS DRILL 324.213",
      "code_information": [
        {
          "code": "3012223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0          323.062",
      "code_information": [
        {
          "code": "3012319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          80-0387",
      "code_information": [
        {
          "code": "3012332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.103",
      "code_information": [
        {
          "code": "3012342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.50x",
      "code_information": [
        {
          "code": "3012358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T7 TORX 703665",
      "code_information": [
        {
          "code": "3012408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 4CHAN 8227411",
      "code_information": [
        {
          "code": "3012587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-ROLLER 24FR WA22038C",
      "code_information": [
        {
          "code": "3012594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING 3.5FR  370-115",
      "code_information": [
        {
          "code": "3013315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-EXTRA STRENGTH GRASPING",
      "code_information": [
        {
          "code": "3013324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE BLUNT 2867-05-220",
      "code_information": [
        {
          "code": "3016132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERTER-SCREW T8   03.617.904",
      "code_information": [
        {
          "code": "3019821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE   28164Mx/3",
      "code_information": [
        {
          "code": "3019825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACIUM 30 CM TUNNELING TOOL",
      "code_information": [
        {
          "code": "3019908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CTR INDIANA TOME  200060",
      "code_information": [
        {
          "code": "3021156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONETTED       3101055",
      "code_information": [
        {
          "code": "3021160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KOH ALL",
      "code_information": [
        {
          "code": "3022136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STR COLD KNIFE K-SB",
      "code_information": [
        {
          "code": "3022228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MULTIFIRE SCORPION",
      "code_information": [
        {
          "code": "3027390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 11M VS101011P",
      "code_information": [
        {
          "code": "3027592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM EYE WENTWORTH",
      "code_information": [
        {
          "code": "3029171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CARTER/MOORE      7959E",
      "code_information": [
        {
          "code": "3029197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "QFIX-DISP SHOULDER 2.8MM",
      "code_information": [
        {
          "code": "3029223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASOPORE  5400-020-008",
      "code_information": [
        {
          "code": "3029293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE RGLR",
      "code_information": [
        {
          "code": "3029340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE XL",
      "code_information": [
        {
          "code": "3029342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-SCREW GUIDE      230790004",
      "code_information": [
        {
          "code": "3030620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STRT 302-431-000",
      "code_information": [
        {
          "code": "3034513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE0-FIAPC CIRCUMFRENTIAL",
      "code_information": [
        {
          "code": "3034521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PNEUMATIC ALL SZ  840-7s",
      "code_information": [
        {
          "code": "3034527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PRASS FLUSH TIP  8225101",
      "code_information": [
        {
          "code": "3034535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICLE SCREW    9450019",
      "code_information": [
        {
          "code": "3034581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-ANASTOCLIP 4001-00",
      "code_information": [
        {
          "code": "3039801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GRAY     ECR45M",
      "code_information": [
        {
          "code": "3039879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60W       GST60W",
      "code_information": [
        {
          "code": "3039929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60T GST60T",
      "code_information": [
        {
          "code": "3039946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3040420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.0 CANN DRI",
      "code_information": [
        {
          "code": "3040703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-SHORT BEVEL 35",
      "code_information": [
        {
          "code": "3058621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 3.0MM",
      "code_information": [
        {
          "code": "3058676",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SM JOINT 2.4MM DRILL&GUID",
      "code_information": [
        {
          "code": "3058763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6MM AR 8943-02",
      "code_information": [
        {
          "code": "3058783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL CONICAL 3+4MM",
      "code_information": [
        {
          "code": "3058870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL WIDENING xMM",
      "code_information": [
        {
          "code": "3058871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED",
      "code_information": [
        {
          "code": "3058948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM xxMM JLATC",
      "code_information": [
        {
          "code": "3059041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-HCS xxMM",
      "code_information": [
        {
          "code": "3059042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR 200-120",
      "code_information": [
        {
          "code": "3059077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 4.3MM",
      "code_information": [
        {
          "code": "3059085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM XFO130022",
      "code_information": [
        {
          "code": "3059096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 15CMX2.2MM 15MH22",
      "code_information": [
        {
          "code": "3059107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X216MM SHORT",
      "code_information": [
        {
          "code": "3059144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X216MM SHORT",
      "code_information": [
        {
          "code": "3059146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTASIS RESOLUTION 36",
      "code_information": [
        {
          "code": "3059208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE GST45W",
      "code_information": [
        {
          "code": "3059268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST45B",
      "code_information": [
        {
          "code": "3059269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45GREEN GST45G",
      "code_information": [
        {
          "code": "3059276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60BLUE GST60B",
      "code_information": [
        {
          "code": "3059280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL MN60MA 00.0",
      "code_information": [
        {
          "code": "3060419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE DISP FIRSTPASS",
      "code_information": [
        {
          "code": "3060480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAGITTAL STD 116170",
      "code_information": [
        {
          "code": "3060497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAG NARROW 116171",
      "code_information": [
        {
          "code": "3060498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5",
      "code_information": [
        {
          "code": "3069109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER MOD.TRINKLE",
      "code_information": [
        {
          "code": "3079260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3081128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE WHITE VASECR35",
      "code_information": [
        {
          "code": "3081553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PUSHLOCK 2.9  AR-1923DS",
      "code_information": [
        {
          "code": "3083078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI SLEEVE 32F 5232B",
      "code_information": [
        {
          "code": "3083150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PROGEL EXTENDED PGEN005-06",
      "code_information": [
        {
          "code": "3083771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-MIDAS LEGEND ALL 14BAxxDC",
      "code_information": [
        {
          "code": "3084380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM         14MH30",
      "code_information": [
        {
          "code": "3084589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 8",
      "code_information": [
        {
          "code": "3084826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT INSTRUM 9733533XOM",
      "code_information": [
        {
          "code": "3084911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT PATIENT",
      "code_information": [
        {
          "code": "3084948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL LONG 5MM      B5XT",
      "code_information": [
        {
          "code": "3085206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12MM         B12LT",
      "code_information": [
        {
          "code": "3085209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 7.5FR MEGA IAB",
      "code_information": [
        {
          "code": "3085536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DISP INSTRUMENT MINI S-TAK",
      "code_information": [
        {
          "code": "3085539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-EXCEL LONG 12MM   B12XT",
      "code_information": [
        {
          "code": "3085625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON         1806-0073S",
      "code_information": [
        {
          "code": "3085870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST60G",
      "code_information": [
        {
          "code": "3086960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6 703702",
      "code_information": [
        {
          "code": "3087918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TWIST DRILL 2.3 72203160",
      "code_information": [
        {
          "code": "3087938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRPAE 3-ARM S.I.E.  420290",
      "code_information": [
        {
          "code": "3139015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 BLUE XI",
      "code_information": [
        {
          "code": "3186035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 GREEN XI",
      "code_information": [
        {
          "code": "3186037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRST 45 WHTE 48645W",
      "code_information": [
        {
          "code": "3186041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-EPISTAT XOMED    15-27031",
      "code_information": [
        {
          "code": "3507977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HELMET-PROTECTIVE SOFT A8000",
      "code_information": [
        {
          "code": "3519273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM 8MM JLATCH",
      "code_information": [
        {
          "code": "3526157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 102MM X 11GA",
      "code_information": [
        {
          "code": "3526202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 152MM X 11GA",
      "code_information": [
        {
          "code": "3526203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO MEASURING 2.0X110MM",
      "code_information": [
        {
          "code": "3526234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-SURGICAL POWDER",
      "code_information": [
        {
          "code": "3526249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO LONG 2.4X140MM",
      "code_information": [
        {
          "code": "3526301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE A0 XTV008001",
      "code_information": [
        {
          "code": "3526333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-COMPLEX BREAST DYNJ60133",
      "code_information": [
        {
          "code": "3526421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC XI DYNJ905698",
      "code_information": [
        {
          "code": "3526424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-NEURO DYNJ60135",
      "code_information": [
        {
          "code": "3526427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW CANN HEX 2.5MM",
      "code_information": [
        {
          "code": "3526498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ASSIST CUSTOM BB10M33R",
      "code_information": [
        {
          "code": "3526535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BARIATRIC DYNJ52366",
      "code_information": [
        {
          "code": "3526671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-PURGE 043-0003",
      "code_information": [
        {
          "code": "3526914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION KNEE AR-12990",
      "code_information": [
        {
          "code": "3526976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EUS 19GA",
      "code_information": [
        {
          "code": "3526981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN DRILL 3.0X170MM 70535",
      "code_information": [
        {
          "code": "3526990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER TORX 703667",
      "code_information": [
        {
          "code": "3527081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST PLEUREVAC A-9250LF",
      "code_information": [
        {
          "code": "3527083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.4X150MM 702448",
      "code_information": [
        {
          "code": "3527149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-MICROBLATOR 30 AC4050-01",
      "code_information": [
        {
          "code": "3527275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3527286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM WHITE 47630W",
      "code_information": [
        {
          "code": "3527881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM BLUE 48630B",
      "code_information": [
        {
          "code": "3527882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN 48630G",
      "code_information": [
        {
          "code": "3527883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-PLASMA STERILE   015",
      "code_information": [
        {
          "code": "3541330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTRODUCER LOCALIZATION",
      "code_information": [
        {
          "code": "3542520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANNULATED 5.0 705361",
      "code_information": [
        {
          "code": "3547933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLACK GST45T",
      "code_information": [
        {
          "code": "3548010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION",
      "code_information": [
        {
          "code": "3549013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION 14FR",
      "code_information": [
        {
          "code": "3549014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 0210",
      "code_information": [
        {
          "code": "3549040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON 50 PASSPORT",
      "code_information": [
        {
          "code": "3549108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6X135MM 703691",
      "code_information": [
        {
          "code": "3549125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.0X135MM 703690",
      "code_information": [
        {
          "code": "3549128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 2.7X122MM 703695",
      "code_information": [
        {
          "code": "3549129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703880",
      "code_information": [
        {
          "code": "3549137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP-50",
      "code_information": [
        {
          "code": "3549153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANN 3.0MM",
      "code_information": [
        {
          "code": "3549162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TORFLEX GUIDING",
      "code_information": [
        {
          "code": "3549175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL HEARTSPAN",
      "code_information": [
        {
          "code": "3549177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP",
      "code_information": [
        {
          "code": "3549202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-BLADE 45-35015",
      "code_information": [
        {
          "code": "3549235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 703896",
      "code_information": [
        {
          "code": "3549240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL 10ML TWIN PK",
      "code_information": [
        {
          "code": "3549261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X230MM 700355",
      "code_information": [
        {
          "code": "3549276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ATSV II BE 8025H",
      "code_information": [
        {
          "code": "3549306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM CANN AR-1218-40",
      "code_information": [
        {
          "code": "3549308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PROFILE AR-1410LP",
      "code_information": [
        {
          "code": "3549310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3549410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACC-SELECTRA IC 50 392290",
      "code_information": [
        {
          "code": "3549414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-3.5 CAN DRILL AR-8956-35P",
      "code_information": [
        {
          "code": "3549430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X122MM 703897",
      "code_information": [
        {
          "code": "3549436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL J-HATCH 14MM",
      "code_information": [
        {
          "code": "3549445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 3.0MM",
      "code_information": [
        {
          "code": "3549453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MINI SUTURE 72290128",
      "code_information": [
        {
          "code": "3549714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SHAFT CANN 6192.0040",
      "code_information": [
        {
          "code": "3549723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 3.5X122MM 703694",
      "code_information": [
        {
          "code": "3549799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3549806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 3.2 X 216 705",
      "code_information": [
        {
          "code": "3549843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 4.3X216 705043",
      "code_information": [
        {
          "code": "3549844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T8 TORX AO 703663",
      "code_information": [
        {
          "code": "3549847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAGNET-REPLACEMENT COCHLEAR",
      "code_information": [
        {
          "code": "3549900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.4X122MM 703696",
      "code_information": [
        {
          "code": "3549904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PILOTED 6.0MM AR-1450",
      "code_information": [
        {
          "code": "3550002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANNU STR",
      "code_information": [
        {
          "code": "3550047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145 03.010.104",
      "code_information": [
        {
          "code": "3550057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-TENSIONER AR-5815",
      "code_information": [
        {
          "code": "3550191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR ACCESS 21030",
      "code_information": [
        {
          "code": "3550197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GJ 22 FR FEEDING 8660-22",
      "code_information": [
        {
          "code": "3550289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563010",
      "code_information": [
        {
          "code": "3550451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563020",
      "code_information": [
        {
          "code": "3550452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563030",
      "code_information": [
        {
          "code": "3550453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563040",
      "code_information": [
        {
          "code": "3550454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASCOPE-RHINOLARYNGO SLIM 51000",
      "code_information": [
        {
          "code": "3550507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERC INSERT AR-1923PK",
      "code_information": [
        {
          "code": "3550583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP 3 BAG SPIKE BLOOD IV",
      "code_information": [
        {
          "code": "3550718",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2009",
      "code_information": [
        {
          "code": "3550763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-910-3500",
      "code_information": [
        {
          "code": "3550772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.6X130MM P99-110-2613",
      "code_information": [
        {
          "code": "3550773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STIM 2862-02-203",
      "code_information": [
        {
          "code": "3550853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4X195MM ST 315.40S",
      "code_information": [
        {
          "code": "3550855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-INFUSION 8FR BIOFLO H787C",
      "code_information": [
        {
          "code": "3550906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.3X100MM P99-100-1310",
      "code_information": [
        {
          "code": "3559004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STERNAL 99-006-01-04",
      "code_information": [
        {
          "code": "3559018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO RESOLUTION 360",
      "code_information": [
        {
          "code": "3559020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENFIT GJ FEEDING 18X45 825",
      "code_information": [
        {
          "code": "3559086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X12MM VASC SIG30TAV",
      "code_information": [
        {
          "code": "3559124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-VAS",
      "code_information": [
        {
          "code": "3559125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 2.3X120MM",
      "code_information": [
        {
          "code": "3559139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN W/AO 2.7MM 705250",
      "code_information": [
        {
          "code": "3559186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 16FR 98437",
      "code_information": [
        {
          "code": "3559429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15X45 XT SIG45AXT",
      "code_information": [
        {
          "code": "3559637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LARYNGOSCOPE-CMOS IDEO RHINO",
      "code_information": [
        {
          "code": "3559674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL VERACROSS",
      "code_information": [
        {
          "code": "3559675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-NAVIGATION TDNC001",
      "code_information": [
        {
          "code": "3559689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM AR-8737-34",
      "code_information": [
        {
          "code": "3598007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PASS STIM DM-8225101",
      "code_information": [
        {
          "code": "3598049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE DBL ABS-10010S",
      "code_information": [
        {
          "code": "3598066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACP+ACD-A ABS-10011T",
      "code_information": [
        {
          "code": "3598067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-14CC MIX ABS-2000",
      "code_information": [
        {
          "code": "3598068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5F 007250P",
      "code_information": [
        {
          "code": "3598088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y-SHAPE SHUNT FV015T",
      "code_information": [
        {
          "code": "3598131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8737-35",
      "code_information": [
        {
          "code": "3598175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI FT CMP AR-8737-41",
      "code_information": [
        {
          "code": "3598177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HOOK/TRI BLADE 2056-6",
      "code_information": [
        {
          "code": "3598195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-915-3500",
      "code_information": [
        {
          "code": "3598232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X60MM 58850025",
      "code_information": [
        {
          "code": "3598253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5.5X60MM 58850055",
      "code_information": [
        {
          "code": "3598254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SCALED 2X150MM 705134",
      "code_information": [
        {
          "code": "3598286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T TRACH SZ10 LT-510-S",
      "code_information": [
        {
          "code": "3598307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-MINIONE M1-1-1824",
      "code_information": [
        {
          "code": "3598321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE SG CTI-10155G",
      "code_information": [
        {
          "code": "3598399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TI-KNOT 5MM 030404",
      "code_information": [
        {
          "code": "3598526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X14MM 03.617.914",
      "code_information": [
        {
          "code": "3598581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X24MM 58850020",
      "code_information": [
        {
          "code": "3598638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY",
      "code_information": [
        {
          "code": "3598673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45",
      "code_information": [
        {
          "code": "3598675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM AR-8737-58",
      "code_information": [
        {
          "code": "3598691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.6 CANN AR-8741-32",
      "code_information": [
        {
          "code": "3598694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT4.0 CA DRILL AR-8956C-40PD",
      "code_information": [
        {
          "code": "3598808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T25 PERIP 5901-1128",
      "code_information": [
        {
          "code": "3599025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 32FR 5532S",
      "code_information": [
        {
          "code": "3599075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 40FR 5540B",
      "code_information": [
        {
          "code": "3599076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8X200MM 03.133.108",
      "code_information": [
        {
          "code": "3599159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/110X30MM 03.133.100",
      "code_information": [
        {
          "code": "3599236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/140X60MM 03.133.101",
      "code_information": [
        {
          "code": "3599240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/170X80 03.133.107",
      "code_information": [
        {
          "code": "3599241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/170X80 03.133.103",
      "code_information": [
        {
          "code": "3599255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X60MM 58850028",
      "code_information": [
        {
          "code": "3599257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 4.2X120 P99-100-421",
      "code_information": [
        {
          "code": "3599394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X130 1806-3550S",
      "code_information": [
        {
          "code": "3599470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-CANN 4MM 705260",
      "code_information": [
        {
          "code": "3599495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.012",
      "code_information": [
        {
          "code": "3599540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TALAR PEG 4MM IB200020",
      "code_information": [
        {
          "code": "3599675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVR 3.5X110 P99-110-3511",
      "code_information": [
        {
          "code": "3599772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STERILE PERC 150MM 9733236",
      "code_information": [
        {
          "code": "3599775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 2MM MR8-15MH22",
      "code_information": [
        {
          "code": "3599776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM MR8-14MH30",
      "code_information": [
        {
          "code": "3599777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 545CC SSZ-X545",
      "code_information": [
        {
          "code": "3599822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 485CC SSZ-F485",
      "code_information": [
        {
          "code": "3599823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 365CC SSZ-F365",
      "code_information": [
        {
          "code": "3599824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 400CC SSZ-X400",
      "code_information": [
        {
          "code": "3599825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BONE BIOPSY CD1110",
      "code_information": [
        {
          "code": "3599838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT DPT5",
      "code_information": [
        {
          "code": "3599926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM AR-18800-19",
      "code_information": [
        {
          "code": "3600284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3X100 MWM100",
      "code_information": [
        {
          "code": "3600385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 3.5X160 P99-110-3516",
      "code_information": [
        {
          "code": "3600392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-NANO 125MM AR-3210-0053",
      "code_information": [
        {
          "code": "3600399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3600410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM SHRT AR-18800-18",
      "code_information": [
        {
          "code": "3600411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CN 2MM AR-8610DB-30C",
      "code_information": [
        {
          "code": "3600487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X140MM P99-100-2814",
      "code_information": [
        {
          "code": "3600522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-LK QR 10MMHEX P45-941-0002",
      "code_information": [
        {
          "code": "3600606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.4X95MM P45-960-2495",
      "code_information": [
        {
          "code": "3600612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM CN DSDS1040",
      "code_information": [
        {
          "code": "3600691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.9 CANN AR-8741-25",
      "code_information": [
        {
          "code": "3600716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUTERSINK-ISO MXM-074-ISO",
      "code_information": [
        {
          "code": "3600769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-18700-20",
      "code_information": [
        {
          "code": "3600864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB SMALL AR-18700-34",
      "code_information": [
        {
          "code": "3600865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM AR-8945-30C",
      "code_information": [
        {
          "code": "3600872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-8967-40C",
      "code_information": [
        {
          "code": "3600876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.5MM 56014500",
      "code_information": [
        {
          "code": "3600979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 2868-20-012",
      "code_information": [
        {
          "code": "3600982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X150 5028-8-150",
      "code_information": [
        {
          "code": "3600991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X300 5028-8-300",
      "code_information": [
        {
          "code": "3600992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 2868-20-014",
      "code_information": [
        {
          "code": "3601008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM LG AR-18800-16",
      "code_information": [
        {
          "code": "3601015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3601016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-18800-49",
      "code_information": [
        {
          "code": "3601017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-6.7MM CANN AR-8967-67C",
      "code_information": [
        {
          "code": "3601045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2MM AO AR-18700-88",
      "code_information": [
        {
          "code": "3601047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X16MM 03.617.916",
      "code_information": [
        {
          "code": "3601076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM PC2-110135",
      "code_information": [
        {
          "code": "3601082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 P20-910-4000",
      "code_information": [
        {
          "code": "3601103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2010",
      "code_information": [
        {
          "code": "3601105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.9X140 P99-110-2914",
      "code_information": [
        {
          "code": "3601117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-RM 2.5X1150MM 351.708S",
      "code_information": [
        {
          "code": "3601122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY EV10",
      "code_information": [
        {
          "code": "3601127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-12MM 86-0712",
      "code_information": [
        {
          "code": "3601252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-14MM 86-0714",
      "code_information": [
        {
          "code": "3601253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3601317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-2-0 ANCHOR W/CAN 4721",
      "code_information": [
        {
          "code": "3601325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLER BLACK 45 48345T",
      "code_information": [
        {
          "code": "3601353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI 1.1MM AR-18700-06",
      "code_information": [
        {
          "code": "3601374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL ENFIT",
      "code_information": [
        {
          "code": "3601439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X160MM P99-100-2816",
      "code_information": [
        {
          "code": "3601457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.6X160MM P99-100-3616",
      "code_information": [
        {
          "code": "3601458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-6.5-5.5X30 MOD 1119.1530",
      "code_information": [
        {
          "code": "3601579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-SHANNON 3MM P99-105-3080S",
      "code_information": [
        {
          "code": "3601619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2/SRT AR-18700-89",
      "code_information": [
        {
          "code": "3601712",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.7MM CSS-072-47-SQ",
      "code_information": [
        {
          "code": "3601732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.1X160MM P99-100-3116",
      "code_information": [
        {
          "code": "3601958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-EXTERNAL TRL 1601",
      "code_information": [
        {
          "code": "3601977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AO AR-18700-58",
      "code_information": [
        {
          "code": "3602020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HEX 2.5 MICA 57S02025",
      "code_information": [
        {
          "code": "3602089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER 60°CVD 1600574",
      "code_information": [
        {
          "code": "3602108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.X220MM AO 703901",
      "code_information": [
        {
          "code": "3602150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE 3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATION-BIASURGE BAS-0101",
      "code_information": [
        {
          "code": "3602440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM LONG AR-8970-30L",
      "code_information": [
        {
          "code": "3602582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP PEARL 5.7MM",
      "code_information": [
        {
          "code": "3602601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP CORAL 4.6MM",
      "code_information": [
        {
          "code": "3602602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CEMENT LL 2839-99-002",
      "code_information": [
        {
          "code": "3602865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DRILL W/NEEDLE 72205692",
      "code_information": [
        {
          "code": "3602934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-UNI PIN P45-970-2000",
      "code_information": [
        {
          "code": "3602946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BLUNT 4X45M P45-196-5045",
      "code_information": [
        {
          "code": "3602947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.4X160MM P45-960-3416",
      "code_information": [
        {
          "code": "3602948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-1H WO/ATTC P45-920-0001",
      "code_information": [
        {
          "code": "3603021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-5MM HLF PN P45-925-0105",
      "code_information": [
        {
          "code": "3603024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3603100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER DOME 7MM P20-070-WD00",
      "code_information": [
        {
          "code": "3603132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL LG 2.4X160M P99-100-2416",
      "code_information": [
        {
          "code": "3603134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 4.5MM AR-8945-45C",
      "code_information": [
        {
          "code": "3603164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3603223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL WIDENING 4MM 92141",
      "code_information": [
        {
          "code": "3603263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X82 P65-105-3030-S",
      "code_information": [
        {
          "code": "3603433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2X8X72 P65-105-2008-S",
      "code_information": [
        {
          "code": "3603436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-3.5X8MM BLUE 48230B",
      "code_information": [
        {
          "code": "3603757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2.5X8MM WHITE 48230W",
      "code_information": [
        {
          "code": "3603758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X8MM GRAY 48230M",
      "code_information": [
        {
          "code": "3603761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.7 FOOTPRINT 72205888",
      "code_information": [
        {
          "code": "3603793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-PLATE TEMP 705019",
      "code_information": [
        {
          "code": "3603817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-BL NEEDLE AR-7289",
      "code_information": [
        {
          "code": "3603840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-STERNAL AR-7288T",
      "code_information": [
        {
          "code": "3603885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP 388.174",
      "code_information": [
        {
          "code": "3603898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP DG 317.781",
      "code_information": [
        {
          "code": "3603899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW T20 57DRVT20",
      "code_information": [
        {
          "code": "3603903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INDUCTIVE HST NR340K9256",
      "code_information": [
        {
          "code": "3603913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUCKLE-INDUCTIVE NR340B9256",
      "code_information": [
        {
          "code": "3603930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QFIX 1.8MM 72290118",
      "code_information": [
        {
          "code": "3603977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FEN JT 2MM PIN MPDP0020",
      "code_information": [
        {
          "code": "3604047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.6 F/4MM MSN10012",
      "code_information": [
        {
          "code": "3604051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X100 P65-105-3031-S",
      "code_information": [
        {
          "code": "3604127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM AR-4160-24",
      "code_information": [
        {
          "code": "3604150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.3 F/4.5MM MSN10006",
      "code_information": [
        {
          "code": "3604155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STIM 8225401",
      "code_information": [
        {
          "code": "3604210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT TPT",
      "code_information": [
        {
          "code": "3604211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X200X100 P65-105-3020-S",
      "code_information": [
        {
          "code": "3604269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK RC AR-3650DS",
      "code_information": [
        {
          "code": "3604296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HD SCORPION AR-13999HDN",
      "code_information": [
        {
          "code": "3604298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLV 1.8X400 643518400",
      "code_information": [
        {
          "code": "3604331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-SMTH 1.8X400 641018400",
      "code_information": [
        {
          "code": "3604332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TRC 3X370 AR-9091K-30",
      "code_information": [
        {
          "code": "3604350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 1.7X120 P99-110-1712",
      "code_information": [
        {
          "code": "3604378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-RELINE C 3990002",
      "code_information": [
        {
          "code": "3604439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO 2.2F/115 CYB-2",
      "code_information": [
        {
          "code": "3604566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 3MM 5820-009-030",
      "code_information": [
        {
          "code": "3604572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 4MM 5820-009-040",
      "code_information": [
        {
          "code": "3604573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MARK OMNI H787137097015",
      "code_information": [
        {
          "code": "3604575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE 28164MC-S",
      "code_information": [
        {
          "code": "3604595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UTERINE 30 KC-RUMI-30",
      "code_information": [
        {
          "code": "3604602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-25",
      "code_information": [
        {
          "code": "3604603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-40",
      "code_information": [
        {
          "code": "3604604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE 48345W",
      "code_information": [
        {
          "code": "3604672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 BLUE 48345B",
      "code_information": [
        {
          "code": "3604673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 100 AR-8964R-150",
      "code_information": [
        {
          "code": "3604778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 250 AR-8964R-250",
      "code_information": [
        {
          "code": "3604779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 300 AR-8964R-300",
      "code_information": [
        {
          "code": "3604780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.5X135MM 542020",
      "code_information": [
        {
          "code": "3604831",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO HF 125 AR-3210-0052",
      "code_information": [
        {
          "code": "3604836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BN 3X900 AR-9095-39S",
      "code_information": [
        {
          "code": "3604848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM CN AR-1218-50",
      "code_information": [
        {
          "code": "3604938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED PRASS 8227304",
      "code_information": [
        {
          "code": "3604956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X145MM 542050",
      "code_information": [
        {
          "code": "3604974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER TUBE 22FR 98433",
      "code_information": [
        {
          "code": "3604979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-3H RANCHO 76-10208",
      "code_information": [
        {
          "code": "3605033",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3MM P20-915-3000",
      "code_information": [
        {
          "code": "3605072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-3.5/SHORT AR-8964-15",
      "code_information": [
        {
          "code": "3605078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-17\\\"\\\" AR-7237-17LN",
      "code_information": [
        {
          "code": "3605098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSSEPTAL FND01902",
      "code_information": [
        {
          "code": "3824363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X14X5MM 607414",
      "code_information": [
        {
          "code": "3900003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X16X6MM 607416",
      "code_information": [
        {
          "code": "3900004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X18X7MM 607418",
      "code_information": [
        {
          "code": "3900005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X20X8MM 607420",
      "code_information": [
        {
          "code": "3900006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X22X9MM 607422",
      "code_information": [
        {
          "code": "3900007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X24X10MM 607424",
      "code_information": [
        {
          "code": "3900008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X26X12MM 607426",
      "code_information": [
        {
          "code": "3900009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X28X14MM 607428",
      "code_information": [
        {
          "code": "3900010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X30X14MM 607430",
      "code_information": [
        {
          "code": "3900011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X32X14MM 607432",
      "code_information": [
        {
          "code": "3900012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X34X14MM 607434",
      "code_information": [
        {
          "code": "3900013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X38X14MM 607438",
      "code_information": [
        {
          "code": "3900014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X40X14MM 607440",
      "code_information": [
        {
          "code": "3900015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X42X14MM 607442",
      "code_information": [
        {
          "code": "3900016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X44X15MM 607444",
      "code_information": [
        {
          "code": "3900017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X46X15MM 607446",
      "code_information": [
        {
          "code": "3900018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X48X15MM 607448",
      "code_information": [
        {
          "code": "3900019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X50X15MM 607450",
      "code_information": [
        {
          "code": "3900020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X55X16MM 607455",
      "code_information": [
        {
          "code": "3900021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X60X16MM 607460",
      "code_information": [
        {
          "code": "3900022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X16MM 607316",
      "code_information": [
        {
          "code": "3900023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X18MM 607318",
      "code_information": [
        {
          "code": "3900024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X20MM 607320",
      "code_information": [
        {
          "code": "3900025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X26MM 607326",
      "code_information": [
        {
          "code": "3900026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X28MM 607328",
      "code_information": [
        {
          "code": "3900027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X30MM 607330",
      "code_information": [
        {
          "code": "3900028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X32MM 607332",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X34MM 607334",
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        {
          "code": "3900030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X36MM 607336",
      "code_information": [
        {
          "code": "3900031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 4X120/35TH 5027-4-120",
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        {
          "code": "3900101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X48MM 661148",
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        {
          "code": "3900219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X65MM 601665",
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        {
          "code": "3900228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X12MM 662512",
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        {
          "code": "3900229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X13MM 662513",
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        {
          "code": "3900230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X14MM 662514",
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        {
          "code": "3900231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X15MM 662515",
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        {
          "code": "3900232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X16MM 662516",
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        {
          "code": "3900233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X18MM 662518",
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        {
          "code": "3900234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X20MM 662520",
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        {
          "code": "3900235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X22MM 662522",
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        {
          "code": "3900236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X24MM 662524",
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        {
          "code": "3900237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X5MM 662505",
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        {
          "code": "3900238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X10MM 661310",
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        {
          "code": "3900249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X12MM 661312",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X14MM 661314",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X16MM 661316",
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          "code": "3900252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK PERI 5X18MM 661318",
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        {
          "code": "3900253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X20MM 661320",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X8MM 661308",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.0X122MM AO 705137",
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        {
          "code": "3900256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X18MM 656618",
      "code_information": [
        {
          "code": "3900257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X20MM 656620",
      "code_information": [
        {
          "code": "3900258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X22MM 656622",
      "code_information": [
        {
          "code": "3900259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X24MM 656624",
      "code_information": [
        {
          "code": "3900260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X26MM 656626",
      "code_information": [
        {
          "code": "3900261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X16MM 656616",
      "code_information": [
        {
          "code": "3900262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X38MM 656338",
      "code_information": [
        {
          "code": "3900273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X40MM 656340",
      "code_information": [
        {
          "code": "3900274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X45MM 656345",
      "code_information": [
        {
          "code": "3900275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X50MM 656350",
      "code_information": [
        {
          "code": "3900276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-WIRE K 1.6X200MM 705136",
      "code_information": [
        {
          "code": "3900277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X105MM 602905",
      "code_information": [
        {
          "code": "3900278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X110MM 602910",
      "code_information": [
        {
          "code": "3900279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X40MM 602640",
      "code_information": [
        {
          "code": "3900280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X45MM 602645",
      "code_information": [
        {
          "code": "3900281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X50MM 602650",
      "code_information": [
        {
          "code": "3900282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X55MM 602655",
      "code_information": [
        {
          "code": "3900283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X60MM 602860",
      "code_information": [
        {
          "code": "3900284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X65MM 602665",
      "code_information": [
        {
          "code": "3900285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X12MM 657612",
      "code_information": [
        {
          "code": "3900294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X13MM 657613",
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        {
          "code": "3900295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X15MM 657615",
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        {
          "code": "3900297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X16MM 657616",
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        {
          "code": "3900298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X18MM 657618",
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        {
          "code": "3900299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X22MM 657622",
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        {
          "code": "3900300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X28MM 657628",
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        {
          "code": "3900303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/1.7MM 57-10391",
      "code_information": [
        {
          "code": "3900462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/2.3 57-15391",
      "code_information": [
        {
          "code": "3900463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7MM 57-10392",
      "code_information": [
        {
          "code": "3900464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7MM 57-10395",
      "code_information": [
        {
          "code": "3900465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/2.3 57-15392",
      "code_information": [
        {
          "code": "3900466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/2.3MM 57-15395",
      "code_information": [
        {
          "code": "3900467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/1.7MM 57-10380",
      "code_information": [
        {
          "code": "3900468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3/LT 57-15324",
      "code_information": [
        {
          "code": "3900469",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 10H/1.7 57-10310",
      "code_information": [
        {
          "code": "3900470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 7H/1.7MM 57-10360",
      "code_information": [
        {
          "code": "3900471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/1.7MM 57-10368",
      "code_information": [
        {
          "code": "3900472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/2.3MM 57-15361",
      "code_information": [
        {
          "code": "3900473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 20H/2X111MM 629640",
      "code_information": [
        {
          "code": "3900485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.0X67MM 629650",
      "code_information": [
        {
          "code": "3900486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2X28MM 629644",
      "code_information": [
        {
          "code": "3900487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2X41MM 629646",
      "code_information": [
        {
          "code": "3900488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.0X54MM 629648",
      "code_information": [
        {
          "code": "3900489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X10H/2.0X62MM 629771",
      "code_information": [
        {
          "code": "3900490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X5H/2X34MM 629770",
      "code_information": [
        {
          "code": "3900491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X10H/2.0X62MM 629773",
      "code_information": [
        {
          "code": "3900492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X5H/2.0X34MM 629772",
      "code_information": [
        {
          "code": "3900493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 5X10H/2.0X62MM 629775",
      "code_information": [
        {
          "code": "3900494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-PIN LENGTHEN 4960-3-020",
      "code_information": [
        {
          "code": "3900495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LENGTHENER 4960-3-010",
      "code_information": [
        {
          "code": "3900496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-RADIAL LONG 54-25401",
      "code_information": [
        {
          "code": "3900497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-RADIAL SHORT 54-25400",
      "code_information": [
        {
          "code": "3900498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 20H/2.4X135 629700",
      "code_information": [
        {
          "code": "3900513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2.4X35 629704",
      "code_information": [
        {
          "code": "3900514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2.4X50MM 629706",
      "code_information": [
        {
          "code": "3900515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.4X65MM 629708",
      "code_information": [
        {
          "code": "3900516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X10H/2.4X76MM 629777",
      "code_information": [
        {
          "code": "3900517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X5H/2.4X41MM 629778",
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        {
          "code": "3900518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 5X10H/2.4X76MM 629781",
      "code_information": [
        {
          "code": "3900519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.7X79MM 629730",
      "code_information": [
        {
          "code": "3900520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 12H/2.4X96MM 629712",
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        {
          "code": "3900521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2.7X32 629724",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2.7X47MM 629726",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.7X64MM 629728",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 20H/2.7X34 629770",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 20H/2X131MM 629660",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2.7X39MM 629744",
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        {
          "code": "3900527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X10H/2.7X87MM 629783",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X5H/2.7X47MM 629782",
      "code_information": [
        {
          "code": "3900529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 5H/98/RT 628225",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CAPSULE DELIVERY 711144",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EUS 22GA",
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          "code": "4825702",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EUS 25GA",
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        },
        {
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OVERTUBE- ESOPHAGEAL 00711146",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD INJECTOR",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 974.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHINCTEROTOME-AUTOTOME RX",
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        },
        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PHOBE-ENCOR BX 7G ECP017G",
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          "code": "7295610",
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        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-STONE 1.9FR     390-105",
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        },
        {
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLUTED 4.0MM  315.40",
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        },
        {
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        }
      ],
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TIB DRILL 195MM     315.29",
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        {
          "code": "3002367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 PERIPH SCREW",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 535.3604,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5",
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          "code": "3002374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X230   1806-35xxS",
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        {
          "code": "3002378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        72-2011",
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        {
          "code": "3002384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 324.214",
      "code_information": [
        {
          "code": "3002392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM 702453",
      "code_information": [
        {
          "code": "3002396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8737-09",
      "code_information": [
        {
          "code": "3002398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 255589000",
      "code_information": [
        {
          "code": "3002401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.0 SCREW DRIVER",
      "code_information": [
        {
          "code": "3002656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1xMM 2868-20-01x",
      "code_information": [
        {
          "code": "3002771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SIZES     703xxx",
      "code_information": [
        {
          "code": "3002789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SZ   2883-01-xxx",
      "code_information": [
        {
          "code": "3012205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0          323.062",
      "code_information": [
        {
          "code": "3012319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          80-0387",
      "code_information": [
        {
          "code": "3012332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.103",
      "code_information": [
        {
          "code": "3012342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CTR INDIANA TOME  200060",
      "code_information": [
        {
          "code": "3021156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE RGLR",
      "code_information": [
        {
          "code": "3029340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE XL",
      "code_information": [
        {
          "code": "3029342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-SCREW GUIDE      230790004",
      "code_information": [
        {
          "code": "3030620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PNEUMATIC ALL SZ  840-7s",
      "code_information": [
        {
          "code": "3034527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PRASS FLUSH TIP  8225101",
      "code_information": [
        {
          "code": "3034535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-ANASTOCLIP 4001-00",
      "code_information": [
        {
          "code": "3039801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GRAY     ECR45M",
      "code_information": [
        {
          "code": "3039879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.0 CANN DRI",
      "code_information": [
        {
          "code": "3040703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 3.0MM",
      "code_information": [
        {
          "code": "3058676",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6MM AR 8943-02",
      "code_information": [
        {
          "code": "3058783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL CONICAL 3+4MM",
      "code_information": [
        {
          "code": "3058870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM xxMM JLATC",
      "code_information": [
        {
          "code": "3059041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-HCS xxMM",
      "code_information": [
        {
          "code": "3059042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM XFO130022",
      "code_information": [
        {
          "code": "3059096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 15CMX2.2MM 15MH22",
      "code_information": [
        {
          "code": "3059107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X216MM SHORT",
      "code_information": [
        {
          "code": "3059144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE GST45W",
      "code_information": [
        {
          "code": "3059268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL MN60MA 00.0",
      "code_information": [
        {
          "code": "3060419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAGITTAL STD 116170",
      "code_information": [
        {
          "code": "3060497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 8",
      "code_information": [
        {
          "code": "3084826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL LONG 5MM      B5XT",
      "code_information": [
        {
          "code": "3085206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 7.5FR MEGA IAB",
      "code_information": [
        {
          "code": "3085536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 BLUE XI",
      "code_information": [
        {
          "code": "3186035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 GREEN XI",
      "code_information": [
        {
          "code": "3186037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRST 45 WHTE 48645W",
      "code_information": [
        {
          "code": "3186041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-EPISTAT XOMED    15-27031",
      "code_information": [
        {
          "code": "3507977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HELMET-PROTECTIVE SOFT A8000",
      "code_information": [
        {
          "code": "3519273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 102MM X 11GA",
      "code_information": [
        {
          "code": "3526202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO MEASURING 2.0X110MM",
      "code_information": [
        {
          "code": "3526234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO LONG 2.4X140MM",
      "code_information": [
        {
          "code": "3526301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-COMPLEX BREAST DYNJ60133",
      "code_information": [
        {
          "code": "3526421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-PURGE 043-0003",
      "code_information": [
        {
          "code": "3526914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER TORX 703667",
      "code_information": [
        {
          "code": "3527081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST PLEUREVAC A-9250LF",
      "code_information": [
        {
          "code": "3527083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-MICROBLATOR 30 AC4050-01",
      "code_information": [
        {
          "code": "3527275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM WHITE 47630W",
      "code_information": [
        {
          "code": "3527881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM BLUE 48630B",
      "code_information": [
        {
          "code": "3527882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION",
      "code_information": [
        {
          "code": "3549013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.0X135MM 703690",
      "code_information": [
        {
          "code": "3549128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 2.7X122MM 703695",
      "code_information": [
        {
          "code": "3549129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703880",
      "code_information": [
        {
          "code": "3549137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TORFLEX GUIDING",
      "code_information": [
        {
          "code": "3549175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL 10ML TWIN PK",
      "code_information": [
        {
          "code": "3549261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM CANN AR-1218-40",
      "code_information": [
        {
          "code": "3549308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 3.2 X 216 705",
      "code_information": [
        {
          "code": "3549843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PILOTED 6.0MM AR-1450",
      "code_information": [
        {
          "code": "3550002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR ACCESS 21030",
      "code_information": [
        {
          "code": "3550197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563010",
      "code_information": [
        {
          "code": "3550451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563020",
      "code_information": [
        {
          "code": "3550452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563030",
      "code_information": [
        {
          "code": "3550453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563040",
      "code_information": [
        {
          "code": "3550454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERC INSERT AR-1923PK",
      "code_information": [
        {
          "code": "3550583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP 3 BAG SPIKE BLOOD IV",
      "code_information": [
        {
          "code": "3550718",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-910-3500",
      "code_information": [
        {
          "code": "3550772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.3X100MM P99-100-1310",
      "code_information": [
        {
          "code": "3559004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X12MM VASC SIG30TAV",
      "code_information": [
        {
          "code": "3559124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 16FR 98437",
      "code_information": [
        {
          "code": "3559429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LARYNGOSCOPE-CMOS IDEO RHINO",
      "code_information": [
        {
          "code": "3559674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-NAVIGATION TDNC001",
      "code_information": [
        {
          "code": "3559689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE DBL ABS-10010S",
      "code_information": [
        {
          "code": "3598066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACP+ACD-A ABS-10011T",
      "code_information": [
        {
          "code": "3598067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI FT CMP AR-8737-41",
      "code_information": [
        {
          "code": "3598177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X60MM 58850025",
      "code_information": [
        {
          "code": "3598253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X14MM 03.617.914",
      "code_information": [
        {
          "code": "3598581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T25 PERIP 5901-1128",
      "code_information": [
        {
          "code": "3599025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 32FR 5532S",
      "code_information": [
        {
          "code": "3599075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 40FR 5540B",
      "code_information": [
        {
          "code": "3599076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8X200MM 03.133.108",
      "code_information": [
        {
          "code": "3599159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/110X30MM 03.133.100",
      "code_information": [
        {
          "code": "3599236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/140X60MM 03.133.101",
      "code_information": [
        {
          "code": "3599240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/170X80 03.133.107",
      "code_information": [
        {
          "code": "3599241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 4.2X120 P99-100-421",
      "code_information": [
        {
          "code": "3599394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X130 1806-3550S",
      "code_information": [
        {
          "code": "3599470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STERILE PERC 150MM 9733236",
      "code_information": [
        {
          "code": "3599775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 2MM MR8-15MH22",
      "code_information": [
        {
          "code": "3599776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 545CC SSZ-X545",
      "code_information": [
        {
          "code": "3599822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 485CC SSZ-F485",
      "code_information": [
        {
          "code": "3599823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 365CC SSZ-F365",
      "code_information": [
        {
          "code": "3599824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT DPT5",
      "code_information": [
        {
          "code": "3599926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM AR-18800-19",
      "code_information": [
        {
          "code": "3600284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-NANO 125MM AR-3210-0053",
      "code_information": [
        {
          "code": "3600399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3600410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM SHRT AR-18800-18",
      "code_information": [
        {
          "code": "3600411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CN 2MM AR-8610DB-30C",
      "code_information": [
        {
          "code": "3600487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X140MM P99-100-2814",
      "code_information": [
        {
          "code": "3600522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.4X95MM P45-960-2495",
      "code_information": [
        {
          "code": "3600612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-18700-20",
      "code_information": [
        {
          "code": "3600864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM AR-8945-30C",
      "code_information": [
        {
          "code": "3600872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-8967-40C",
      "code_information": [
        {
          "code": "3600876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.5MM 56014500",
      "code_information": [
        {
          "code": "3600979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 2868-20-012",
      "code_information": [
        {
          "code": "3600982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X150 5028-8-150",
      "code_information": [
        {
          "code": "3600991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X300 5028-8-300",
      "code_information": [
        {
          "code": "3600992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM LG AR-18800-16",
      "code_information": [
        {
          "code": "3601015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3601016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.9X140 P99-110-2914",
      "code_information": [
        {
          "code": "3601117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-12MM 86-0712",
      "code_information": [
        {
          "code": "3601252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLER BLACK 45 48345T",
      "code_information": [
        {
          "code": "3601353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL ENFIT",
      "code_information": [
        {
          "code": "3601439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X160MM P99-100-2816",
      "code_information": [
        {
          "code": "3601457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.6X160MM P99-100-3616",
      "code_information": [
        {
          "code": "3601458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2/SRT AR-18700-89",
      "code_information": [
        {
          "code": "3601712",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.7MM CSS-072-47-SQ",
      "code_information": [
        {
          "code": "3601732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.1X160MM P99-100-3116",
      "code_information": [
        {
          "code": "3601958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP PEARL 5.7MM",
      "code_information": [
        {
          "code": "3602601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DRILL W/NEEDLE 72205692",
      "code_information": [
        {
          "code": "3602934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-UNI PIN P45-970-2000",
      "code_information": [
        {
          "code": "3602946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BLUNT 4X45M P45-196-5045",
      "code_information": [
        {
          "code": "3602947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.4X160MM P45-960-3416",
      "code_information": [
        {
          "code": "3602948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-5MM HLF PN P45-925-0105",
      "code_information": [
        {
          "code": "3603024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3603100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER DOME 7MM P20-070-WD00",
      "code_information": [
        {
          "code": "3603132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL LG 2.4X160M P99-100-2416",
      "code_information": [
        {
          "code": "3603134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2X8X72 P65-105-2008-S",
      "code_information": [
        {
          "code": "3603436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-3.5X8MM BLUE 48230B",
      "code_information": [
        {
          "code": "3603757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.7 FOOTPRINT 72205888",
      "code_information": [
        {
          "code": "3603793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-PLATE TEMP 705019",
      "code_information": [
        {
          "code": "3603817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP 388.174",
      "code_information": [
        {
          "code": "3603898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW T20 57DRVT20",
      "code_information": [
        {
          "code": "3603903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.6 F/4MM MSN10012",
      "code_information": [
        {
          "code": "3604051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM AR-4160-24",
      "code_information": [
        {
          "code": "3604150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STIM 8225401",
      "code_information": [
        {
          "code": "3604210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLV 1.8X400 643518400",
      "code_information": [
        {
          "code": "3604331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-SMTH 1.8X400 641018400",
      "code_information": [
        {
          "code": "3604332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 1.7X120 P99-110-1712",
      "code_information": [
        {
          "code": "3604378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO 2.2F/115 CYB-2",
      "code_information": [
        {
          "code": "3604566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 3MM 5820-009-030",
      "code_information": [
        {
          "code": "3604572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UTERINE 30 KC-RUMI-30",
      "code_information": [
        {
          "code": "3604602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-25",
      "code_information": [
        {
          "code": "3604603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONTROLLER-AZUR DETACH 45-4001",
      "code_information": [
        {
          "code": "1411129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 3FR 0   390-103",
      "code_information": [
        {
          "code": "3002153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3889.9195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-1.3F NITINOL STONE",
      "code_information": [
        {
          "code": "3002170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 2.0",
      "code_information": [
        {
          "code": "3002254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1209.5175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0          357.407",
      "code_information": [
        {
          "code": "3002356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1989.7258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              316.286",
      "code_information": [
        {
          "code": "3002781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1655.5097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT ALL    18-84004HR",
      "code_information": [
        {
          "code": "3003228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2744.9096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACCESS 10 GAUGE",
      "code_information": [
        {
          "code": "3012102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1155.0197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SKYLINE 14MM   286820014",
      "code_information": [
        {
          "code": "3012132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING 3.5FR  370-115",
      "code_information": [
        {
          "code": "3013315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1142.7855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-EXTRA STRENGTH GRASPING",
      "code_information": [
        {
          "code": "3013324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2243.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERTER-SCREW T8   03.617.904",
      "code_information": [
        {
          "code": "3019821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1139.4489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE   28164Mx/3",
      "code_information": [
        {
          "code": "3019825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2981.2521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACIUM 30 CM TUNNELING TOOL",
      "code_information": [
        {
          "code": "3019908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1366.3377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KOH ALL",
      "code_information": [
        {
          "code": "3022136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1434.1819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STR COLD KNIFE K-SB",
      "code_information": [
        {
          "code": "3022228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM EYE WENTWORTH",
      "code_information": [
        {
          "code": "3029171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1392.4744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "QFIX-DISP SHOULDER 2.8MM",
      "code_information": [
        {
          "code": "3029223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1455.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STRT 302-431-000",
      "code_information": [
        {
          "code": "3034513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5897.4405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE0-FIAPC CIRCUMFRENTIAL",
      "code_information": [
        {
          "code": "3034521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1284.0349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60W       GST60W",
      "code_information": [
        {
          "code": "3039929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1146.1221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3040420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1692.2123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SM JOINT 2.4MM DRILL&GUID",
      "code_information": [
        {
          "code": "3058763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL WIDENING xMM",
      "code_information": [
        {
          "code": "3058871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7124.7532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR 200-120",
      "code_information": [
        {
          "code": "3059077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X216MM SHORT",
      "code_information": [
        {
          "code": "3059146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4823.6114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST45B",
      "code_information": [
        {
          "code": "3059269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45GREEN GST45G",
      "code_information": [
        {
          "code": "3059276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8426.0272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAG NARROW 116171",
      "code_information": [
        {
          "code": "3060498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PUSHLOCK 2.9  AR-1923DS",
      "code_information": [
        {
          "code": "3083078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3731.9871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI SLEEVE 32F 5232B",
      "code_information": [
        {
          "code": "3083150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1926.3304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PROGEL EXTENDED PGEN005-06",
      "code_information": [
        {
          "code": "3083771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 14081.5642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM         14MH30",
      "code_information": [
        {
          "code": "3084589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT INSTRUM 9733533XOM",
      "code_information": [
        {
          "code": "3084911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT PATIENT",
      "code_information": [
        {
          "code": "3084948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2211.6097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6 703702",
      "code_information": [
        {
          "code": "3087918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7526.2574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM 8MM JLATCH",
      "code_information": [
        {
          "code": "3526157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 152MM X 11GA",
      "code_information": [
        {
          "code": "3526203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW CANN HEX 2.5MM",
      "code_information": [
        {
          "code": "3526498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2073.1408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ASSIST CUSTOM BB10M33R",
      "code_information": [
        {
          "code": "3526535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4134.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION KNEE AR-12990",
      "code_information": [
        {
          "code": "3526976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EUS 19GA",
      "code_information": [
        {
          "code": "3526981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9711.7304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN DRILL 3.0X170MM 70535",
      "code_information": [
        {
          "code": "3526990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7167.5729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.4X150MM 702448",
      "code_information": [
        {
          "code": "3527149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6548.0775,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLACK GST45T",
      "code_information": [
        {
          "code": "3548010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION 14FR",
      "code_information": [
        {
          "code": "3549014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 0210",
      "code_information": [
        {
          "code": "3549040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON 50 PASSPORT",
      "code_information": [
        {
          "code": "3549108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP-50",
      "code_information": [
        {
          "code": "3549153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANN 3.0MM",
      "code_information": [
        {
          "code": "3549162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9536.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL HEARTSPAN",
      "code_information": [
        {
          "code": "3549177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP",
      "code_information": [
        {
          "code": "3549202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1486.4553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-BLADE 45-35015",
      "code_information": [
        {
          "code": "3549235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2951.2227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 703896",
      "code_information": [
        {
          "code": "3549240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4966.5291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X230MM 700355",
      "code_information": [
        {
          "code": "3549276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 10602.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACC-SELECTRA IC 50 392290",
      "code_information": [
        {
          "code": "3549414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5416.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X122MM 703897",
      "code_information": [
        {
          "code": "3549436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8520.0081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL J-HATCH 14MM",
      "code_information": [
        {
          "code": "3549445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 3.0MM",
      "code_information": [
        {
          "code": "3549453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SHAFT CANN 6192.0040",
      "code_information": [
        {
          "code": "3549723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3174.7749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 3.5X122MM 703694",
      "code_information": [
        {
          "code": "3549799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3549806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 4.3X216 705043",
      "code_information": [
        {
          "code": "3549844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAGNET-REPLACEMENT COCHLEAR",
      "code_information": [
        {
          "code": "3549900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.4X122MM 703696",
      "code_information": [
        {
          "code": "3549904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145 03.010.104",
      "code_information": [
        {
          "code": "3550057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-TENSIONER AR-5815",
      "code_information": [
        {
          "code": "3550191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5420.8628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GJ 22 FR FEEDING 8660-22",
      "code_information": [
        {
          "code": "3550289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASCOPE-RHINOLARYNGO SLIM 51000",
      "code_information": [
        {
          "code": "3550507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STIM 2862-02-203",
      "code_information": [
        {
          "code": "3550853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 11041.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4X195MM ST 315.40S",
      "code_information": [
        {
          "code": "3550855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 29277.5528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-INFUSION 8FR BIOFLO H787C",
      "code_information": [
        {
          "code": "3550906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1978.0477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STERNAL 99-006-01-04",
      "code_information": [
        {
          "code": "3559018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3981.676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 2.3X120MM",
      "code_information": [
        {
          "code": "3559139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15X45 XT SIG45AXT",
      "code_information": [
        {
          "code": "3559637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4925.9338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL VERACROSS",
      "code_information": [
        {
          "code": "3559675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1586.5533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM AR-8737-34",
      "code_information": [
        {
          "code": "3598007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9912.4825,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PASS STIM DM-8225101",
      "code_information": [
        {
          "code": "3598049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7374.4421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-14CC MIX ABS-2000",
      "code_information": [
        {
          "code": "3598068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5F 007250P",
      "code_information": [
        {
          "code": "3598088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y-SHAPE SHUNT FV015T",
      "code_information": [
        {
          "code": "3598131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1255.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HOOK/TRI BLADE 2056-6",
      "code_information": [
        {
          "code": "3598195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-915-3500",
      "code_information": [
        {
          "code": "3598232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2358.9762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5.5X60MM 58850055",
      "code_information": [
        {
          "code": "3598254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1246.7762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SCALED 2X150MM 705134",
      "code_information": [
        {
          "code": "3598286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T TRACH SZ10 LT-510-S",
      "code_information": [
        {
          "code": "3598307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3857.6657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-MINIONE M1-1-1824",
      "code_information": [
        {
          "code": "3598321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45",
      "code_information": [
        {
          "code": "3598675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM AR-8737-58",
      "code_information": [
        {
          "code": "3598691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT4.0 CA DRILL AR-8956C-40PD",
      "code_information": [
        {
          "code": "3598808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X60MM 58850028",
      "code_information": [
        {
          "code": "3599257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-CANN 4MM 705260",
      "code_information": [
        {
          "code": "3599495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3409.4491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.012",
      "code_information": [
        {
          "code": "3599540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1688.3196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TALAR PEG 4MM IB200020",
      "code_information": [
        {
          "code": "3599675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM MR8-14MH30",
      "code_information": [
        {
          "code": "3599777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3775.3629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 400CC SSZ-X400",
      "code_information": [
        {
          "code": "3599825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3X100 MWM100",
      "code_information": [
        {
          "code": "3600385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 10446.8946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 3.5X160 P99-110-3516",
      "code_information": [
        {
          "code": "3600392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2640.9189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM CN DSDS1040",
      "code_information": [
        {
          "code": "3600691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB SMALL AR-18700-34",
      "code_information": [
        {
          "code": "3600865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2515.2403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-6.7MM CANN AR-8967-67C",
      "code_information": [
        {
          "code": "3601045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2926.7543,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X16MM 03.617.916",
      "code_information": [
        {
          "code": "3601076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2775.4951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM PC2-110135",
      "code_information": [
        {
          "code": "3601082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1960.8086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 P20-910-4000",
      "code_information": [
        {
          "code": "3601103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY EV10",
      "code_information": [
        {
          "code": "3601127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-14MM 86-0714",
      "code_information": [
        {
          "code": "3601253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3601317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8783.5995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-2-0 ANCHOR W/CAN 4721",
      "code_information": [
        {
          "code": "3601325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2762.1487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-6.5-5.5X30 MOD 1119.1530",
      "code_information": [
        {
          "code": "3601579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-SHANNON 3MM P99-105-3080S",
      "code_information": [
        {
          "code": "3601619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3561.2644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AO AR-18700-58",
      "code_information": [
        {
          "code": "3602020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6837.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HEX 2.5 MICA 57S02025",
      "code_information": [
        {
          "code": "3602089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.X220MM AO 703901",
      "code_information": [
        {
          "code": "3602150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE 3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3788.7093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATION-BIASURGE BAS-0101",
      "code_information": [
        {
          "code": "3602440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1735.5881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP CORAL 4.6MM",
      "code_information": [
        {
          "code": "3602602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CEMENT LL 2839-99-002",
      "code_information": [
        {
          "code": "3602865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL WIDENING 4MM 92141",
      "code_information": [
        {
          "code": "3603263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3611.8695,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X82 P65-105-3030-S",
      "code_information": [
        {
          "code": "3603433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4037.286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2.5X8MM WHITE 48230W",
      "code_information": [
        {
          "code": "3603758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X8MM GRAY 48230M",
      "code_information": [
        {
          "code": "3603761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 34308.5895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-BL NEEDLE AR-7289",
      "code_information": [
        {
          "code": "3603840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-STERNAL AR-7288T",
      "code_information": [
        {
          "code": "3603885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP DG 317.781",
      "code_information": [
        {
          "code": "3603899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1869.6082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QFIX 1.8MM 72290118",
      "code_information": [
        {
          "code": "3603977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FEN JT 2MM PIN MPDP0020",
      "code_information": [
        {
          "code": "3604047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X100 P65-105-3031-S",
      "code_information": [
        {
          "code": "3604127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT TPT",
      "code_information": [
        {
          "code": "3604211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1944.1256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X200X100 P65-105-3020-S",
      "code_information": [
        {
          "code": "3604269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HD SCORPION AR-13999HDN",
      "code_information": [
        {
          "code": "3604298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1843.4715,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TRC 3X370 AR-9091K-30",
      "code_information": [
        {
          "code": "3604350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1586.5533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-RELINE C 3990002",
      "code_information": [
        {
          "code": "3604439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2243.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 4MM 5820-009-040",
      "code_information": [
        {
          "code": "3604573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE 28164MC-S",
      "code_information": [
        {
          "code": "3604595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1248.4445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-40",
      "code_information": [
        {
          "code": "3604604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FUNNEL-KELLER 2 HA-005",
      "code_information": [
        {
          "code": "3000004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 498.2656,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM     03.617.9xx",
      "code_information": [
        {
          "code": "3002371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT 2.9MM    18-82904",
      "code_information": [
        {
          "code": "3003237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 127.3469,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER     62-27015",
      "code_information": [
        {
          "code": "3003253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 347.0064,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO              CYB-x",
      "code_information": [
        {
          "code": "3003505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 72.293,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION xMM 5820-009-0xx",
      "code_information": [
        {
          "code": "3003845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 175.1715,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 29FR 96370-029",
      "code_information": [
        {
          "code": "3004237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 10M OMS-T10BT",
      "code_information": [
        {
          "code": "3005080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-OMEGA        1004930",
      "code_information": [
        {
          "code": "3009748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ENDO LINEAR       ATS45",
      "code_information": [
        {
          "code": "3009970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 238.0108,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-PERCUTANEOUS DRILL 324.213",
      "code_information": [
        {
          "code": "3012223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.50x",
      "code_information": [
        {
          "code": "3012358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 427.6409,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T7 TORX 703665",
      "code_information": [
        {
          "code": "3012408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 134.0201,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 4CHAN 8227411",
      "code_information": [
        {
          "code": "3012587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 305.2989,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-ROLLER 24FR WA22038C",
      "code_information": [
        {
          "code": "3012594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 206.8692,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE BLUNT 2867-05-220",
      "code_information": [
        {
          "code": "3016132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 173.5032,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONETTED       3101055",
      "code_information": [
        {
          "code": "3021160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 146.2543,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MULTIFIRE SCORPION",
      "code_information": [
        {
          "code": "3027390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 243.0157,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 11M VS101011P",
      "code_information": [
        {
          "code": "3027592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 333.66,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CARTER/MOORE      7959E",
      "code_information": [
        {
          "code": "3029197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 56.7222,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASOPORE  5400-020-008",
      "code_information": [
        {
          "code": "3029293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 353.6796,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICLE SCREW    9450019",
      "code_information": [
        {
          "code": "3034581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 112.3322,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60T GST60T",
      "code_information": [
        {
          "code": "3039946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 258.5865,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-SHORT BEVEL 35",
      "code_information": [
        {
          "code": "3058621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 245.7962,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED",
      "code_information": [
        {
          "code": "3058948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 130.6835,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 4.3MM",
      "code_information": [
        {
          "code": "3059085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 166.2739,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTASIS RESOLUTION 36",
      "code_information": [
        {
          "code": "3059208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 42.8197,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60BLUE GST60B",
      "code_information": [
        {
          "code": "3059280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 155.1519,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE DISP FIRSTPASS",
      "code_information": [
        {
          "code": "3060480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5",
      "code_information": [
        {
          "code": "3069109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 488.8119,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER MOD.TRINKLE",
      "code_information": [
        {
          "code": "3079260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 245.7962,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3081128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 330.3234,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE WHITE VASECR35",
      "code_information": [
        {
          "code": "3081553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 439.8751,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-MIDAS LEGEND ALL 14BAxxDC",
      "code_information": [
        {
          "code": "3084380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 291.9525,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12MM         B12LT",
      "code_information": [
        {
          "code": "3085209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 239.123,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DISP INSTRUMENT MINI S-TAK",
      "code_information": [
        {
          "code": "3085539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 124.0103,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-EXCEL LONG 12MM   B12XT",
      "code_information": [
        {
          "code": "3085625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 149.0348,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON         1806-0073S",
      "code_information": [
        {
          "code": "3085870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 176.8398,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST60G",
      "code_information": [
        {
          "code": "3086960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 452.1093,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TWIST DRILL 2.3 72203160",
      "code_information": [
        {
          "code": "3087938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 451.5532,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRPAE 3-ARM S.I.E.  420290",
      "code_information": [
        {
          "code": "3139015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-SURGICAL POWDER",
      "code_information": [
        {
          "code": "3526249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 7.7854,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE A0 XTV008001",
      "code_information": [
        {
          "code": "3526333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 63.3954,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC XI DYNJ905698",
      "code_information": [
        {
          "code": "3526424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 426.5287,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-NEURO DYNJ60135",
      "code_information": [
        {
          "code": "3526427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 341.4454,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BARIATRIC DYNJ52366",
      "code_information": [
        {
          "code": "3526671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 61.7271,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3527286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 330.3234,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN 48630G",
      "code_information": [
        {
          "code": "3527883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-PLASMA STERILE   015",
      "code_information": [
        {
          "code": "3541330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 88.976,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTRODUCER LOCALIZATION",
      "code_information": [
        {
          "code": "3542520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 72.293,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANNULATED 5.0 705361",
      "code_information": [
        {
          "code": "3547933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6X135MM 703691",
      "code_information": [
        {
          "code": "3549125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ATSV II BE 8025H",
      "code_information": [
        {
          "code": "3549306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 298.6257,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PROFILE AR-1410LP",
      "code_information": [
        {
          "code": "3549310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 199.0838,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3549410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 311.9721,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-3.5 CAN DRILL AR-8956-35P",
      "code_information": [
        {
          "code": "3549430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 206.8692,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MINI SUTURE 72290128",
      "code_information": [
        {
          "code": "3549714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T8 TORX AO 703663",
      "code_information": [
        {
          "code": "3549847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 493.8168,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANNU STR",
      "code_information": [
        {
          "code": "3550047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 172.9471,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2009",
      "code_information": [
        {
          "code": "3550763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.6X130MM P99-110-2613",
      "code_information": [
        {
          "code": "3550773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO RESOLUTION 360",
      "code_information": [
        {
          "code": "3559020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 39.4831,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENFIT GJ FEEDING 18X45 825",
      "code_information": [
        {
          "code": "3559086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 126.7908,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-VAS",
      "code_information": [
        {
          "code": "3559125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN W/AO 2.7MM 705250",
      "code_information": [
        {
          "code": "3559186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 339.7771,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8737-35",
      "code_information": [
        {
          "code": "3598175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 182.4008,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE SG CTI-10155G",
      "code_information": [
        {
          "code": "3598399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 7.7854,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TI-KNOT 5MM 030404",
      "code_information": [
        {
          "code": "3598526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 285.2793,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X24MM 58850020",
      "code_information": [
        {
          "code": "3598638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 418.1872,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY",
      "code_information": [
        {
          "code": "3598673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 58.9466,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.6 CANN AR-8741-32",
      "code_information": [
        {
          "code": "3598694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 151.2592,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/170X80 03.133.103",
      "code_information": [
        {
          "code": "3599255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 181.2886,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVR 3.5X110 P99-110-3511",
      "code_information": [
        {
          "code": "3599772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 99.5419,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BONE BIOPSY CD1110",
      "code_information": [
        {
          "code": "3599838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-LK QR 10MMHEX P45-941-0002",
      "code_information": [
        {
          "code": "3600606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 149.5909,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.9 CANN AR-8741-25",
      "code_information": [
        {
          "code": "3600716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 219.1034,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUTERSINK-ISO MXM-074-ISO",
      "code_information": [
        {
          "code": "3600769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 384.8212,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 2868-20-014",
      "code_information": [
        {
          "code": "3601008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 108.9956,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-18800-49",
      "code_information": [
        {
          "code": "3601017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 232.4498,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2MM AO AR-18700-88",
      "code_information": [
        {
          "code": "3601047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 231.8937,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2010",
      "code_information": [
        {
          "code": "3601105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-RM 2.5X1150MM 351.708S",
      "code_information": [
        {
          "code": "3601122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 372.0309,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI 1.1MM AR-18700-06",
      "code_information": [
        {
          "code": "3601374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 165.7178,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-EXTERNAL TRL 1601",
      "code_information": [
        {
          "code": "3601977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 291.9525,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER 60°CVD 1600574",
      "code_information": [
        {
          "code": "3602108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 60.0588,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM LONG AR-8970-30L",
      "code_information": [
        {
          "code": "3602582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-1H WO/ATTC P45-920-0001",
      "code_information": [
        {
          "code": "3603021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 378.7041,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 4.5MM AR-8945-45C",
      "code_information": [
        {
          "code": "3603164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3603223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 41.7075,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INDUCTIVE HST NR340K9256",
      "code_information": [
        {
          "code": "3603913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 379.2602,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUCKLE-INDUCTIVE NR340B9256",
      "code_information": [
        {
          "code": "3603930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 113.4444,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.3 F/4.5MM MSN10006",
      "code_information": [
        {
          "code": "3604155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 398.1676,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK RC AR-3650DS",
      "code_information": [
        {
          "code": "3604296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 222.9961,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MARK OMNI H787137097015",
      "code_information": [
        {
          "code": "3604575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 111.22,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "1100160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYN            ALLSZs",
      "code_information": [
        {
          "code": "1100275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 1385.8012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.1246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC PED 10FR    8010",
      "code_information": [
        {
          "code": "1102034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 12FR PEDS   8012",
      "code_information": [
        {
          "code": "1102046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.1898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK BABY",
      "code_information": [
        {
          "code": "1102135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 426.5287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.1329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC 3-LUMEN PWR INJ SAFET",
      "code_information": [
        {
          "code": "1110365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 201.8643,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 473.1201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH LUMEN 4FR    AK-14402",
      "code_information": [
        {
          "code": "1110376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 38.927,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "1113245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 240.2352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS          G04153",
      "code_information": [
        {
          "code": "1113258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 465.4557,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 266.477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-FOREIGN BODY   FB-5000",
      "code_information": [
        {
          "code": "1115735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 837,
          "minimum": 58.9466,
          "maximum": 607.4109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 516.2993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEONATE TUBE RESV",
      "code_information": [
        {
          "code": "1115845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 911.4479,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATHETER CRICOTHYROTOMY",
      "code_information": [
        {
          "code": "1118135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1639,
          "minimum": 31.1416,
          "maximum": 1189.4223,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1011.009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-HANGING CAST LG 1180LPP",
      "code_information": [
        {
          "code": "1118520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "1118720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 116.781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "1118735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 210,
          "minimum": 71.7916,
          "maximum": 636.7345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 129.5375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "#1855G 5-0 ETHILON PC-1",
      "code_information": [
        {
          "code": "1118792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 49,
          "minimum": 16.7514,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 30.2254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EVAC/DRAIN 1-BTL  62287",
      "code_information": [
        {
          "code": "1118801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 188.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED       8CFN",
      "code_information": [
        {
          "code": "1118955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 339,
          "minimum": 22.8001,
          "maximum": 246.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 209.1105,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "1119001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 41,
          "minimum": 14.0165,
          "maximum": 29.7537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 25.2906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "1119800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 48,
          "minimum": 16.4095,
          "maximum": 2677.6215,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 29.6086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-15      G00012",
      "code_information": [
        {
          "code": "1410067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 147.5333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINL 22X20     G03542",
      "code_information": [
        {
          "code": "1410472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 256,
          "minimum": 87.5174,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 157.9123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CUSTOM WASTE BAG",
      "code_information": [
        {
          "code": "1410792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.35,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-INDIGO W/TUBING IAPS2",
      "code_information": [
        {
          "code": "1410803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 825.9455,
          "maximum": 2100.3897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1490.2975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INFUSION MRI          1056",
      "code_information": [
        {
          "code": "1410839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.6596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE ADAPTER MRI   1057",
      "code_information": [
        {
          "code": "1410840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 153.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.7711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18G 20CM   G01047",
      "code_information": [
        {
          "code": "1410918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.4615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18-15      G03954",
      "code_information": [
        {
          "code": "1411193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 217,
          "minimum": 74.1847,
          "maximum": 549.4268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.8554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MONOPTY 18X10    121810",
      "code_information": [
        {
          "code": "1411612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 63.9515,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.2872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JAR-COPLIN PP STAIN     S90130",
      "code_information": [
        {
          "code": "1411903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION     CID-20-30",
      "code_information": [
        {
          "code": "1412310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 734,
          "minimum": 250.9288,
          "maximum": 631.1735,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 452.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE .010-.038   TD01",
      "code_information": [
        {
          "code": "1412325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 87.3077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-STAYFIX SMALL    680-ME",
      "code_information": [
        {
          "code": "1412330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 53.6728,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.8447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL IV 6FR   48-152",
      "code_information": [
        {
          "code": "1412380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL ALL 48-100's",
      "code_information": [
        {
          "code": "1412394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 85.0833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.0487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX ALL SZ",
      "code_information": [
        {
          "code": "1413165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 591,
          "minimum": 202.0421,
          "maximum": 428.8887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 364.5554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX ALL SZ",
      "code_information": [
        {
          "code": "1413170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 523,
          "minimum": 120.6737,
          "maximum": 379.5411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 322.6099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN ALL SZS G01xxx",
      "code_information": [
        {
          "code": "1414845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 285.2793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY ALL SZS",
      "code_information": [
        {
          "code": "1414866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 757.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 262.776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-10      G01112",
      "code_information": [
        {
          "code": "1414935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "1414990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 77.9452,
          "maximum": 165.4596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.6407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X     C20xxA",
      "code_information": [
        {
          "code": "1414995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-IV SILVERSITE 1X7MM",
      "code_information": [
        {
          "code": "1415449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 2767.7097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-VASCULAR 6MM X 7MM X 5FR",
      "code_information": [
        {
          "code": "1415480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT GASTRO INITIAL SM",
      "code_information": [
        {
          "code": "1415943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 987,
          "minimum": 337.4206,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 608.826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-150 ML ILLUMENA 900103",
      "code_information": [
        {
          "code": "1416100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 2008.0771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGIOGRAPHY    MCBK001-07",
      "code_information": [
        {
          "code": "1416236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 783,
          "minimum": 267.6802,
          "maximum": 1974.7111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 482.9896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22FR   0250-22",
      "code_information": [
        {
          "code": "1416370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 396.4993,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 966.5961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENTUIT THRIVE 14F",
      "code_information": [
        {
          "code": "1416371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 713,
          "minimum": 243.7496,
          "maximum": 1623.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 439.8105,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-INDIGO             IST3",
      "code_information": [
        {
          "code": "1416377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2920,
          "minimum": 998.2454,
          "maximum": 2119.044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1801.1874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1419101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX11C",
      "code_information": [
        {
          "code": "1419112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX15C",
      "code_information": [
        {
          "code": "1419113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 20GX15C",
      "code_information": [
        {
          "code": "1419114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX11C",
      "code_information": [
        {
          "code": "1419116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX15C",
      "code_information": [
        {
          "code": "1419118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 601,
          "minimum": 205.4608,
          "maximum": 436.1457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 370.7238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX20C",
      "code_information": [
        {
          "code": "1419119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 601,
          "minimum": 205.4608,
          "maximum": 436.1457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 370.7238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY  20GX11C",
      "code_information": [
        {
          "code": "1419293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 451,
          "minimum": 154.1811,
          "maximum": 556.6561,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 278.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-BIOPSY EVIVA 9G",
      "code_information": [
        {
          "code": "1495152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 39.4831,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-TISSUE ATEC        TF-1",
      "code_information": [
        {
          "code": "1495228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-EVIVA STX   0913-12T",
      "code_information": [
        {
          "code": "1495304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 172.9471,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE MULTICARE  MME-00347",
      "code_information": [
        {
          "code": "1495418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 352.5674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 191.8388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC",
      "code_information": [
        {
          "code": "2395902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 79.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC 50MM",
      "code_information": [
        {
          "code": "2395904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 310.8599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAT-SURGISAFE ABSORBANT FLOOR",
      "code_information": [
        {
          "code": "3000001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 323,
          "minimum": 110.4223,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.2409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-FULL RADIUS 5.5MM",
      "code_information": [
        {
          "code": "3000006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.6931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO               2C4040",
      "code_information": [
        {
          "code": "3000090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CONFIDENCE 2839-99-002",
      "code_information": [
        {
          "code": "3000520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-HEMOSTASES  HC0001",
      "code_information": [
        {
          "code": "3000742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1597,
          "minimum": 545.9582,
          "maximum": 1158.9429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 985.1015,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-CLIP MED/LG 20 SMC",
      "code_information": [
        {
          "code": "3000753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 141.8055,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 621.1629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP PK AM0004",
      "code_information": [
        {
          "code": "3000760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 185.0535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 157.2955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP    AM0005",
      "code_information": [
        {
          "code": "3000762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 11638.0608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.3904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP  DISP   MCM20",
      "code_information": [
        {
          "code": "3000765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 518,
          "minimum": 177.086,
          "maximum": 375.9126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.5257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP LARGE MCL20",
      "code_information": [
        {
          "code": "3000766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 553,
          "minimum": 189.0513,
          "maximum": 401.3121,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 341.1153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP SM MCS20",
      "code_information": [
        {
          "code": "3000767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 569,
          "minimum": 194.5211,
          "maximum": 720.1495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 350.9848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-AUTOMATIC 5MM AE05ML",
      "code_information": [
        {
          "code": "3000770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 798.8143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-ANASTOCLIP LARGE 15CM",
      "code_information": [
        {
          "code": "3000773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSISTANT-SUTURE 5MM     SW100",
      "code_information": [
        {
          "code": "3000865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1311,
          "minimum": 448.1848,
          "maximum": 2858.354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 808.6838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-UROLOGIC DRAIN     9501000",
      "code_information": [
        {
          "code": "3001113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 360.9089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.5185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-ANCHOR TISSUE ROBOTIC",
      "code_information": [
        {
          "code": "3001135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 649,
          "minimum": 221.8703,
          "maximum": 470.9793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 400.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-ENDOPOUCH 10MM POUCH",
      "code_information": [
        {
          "code": "3001190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-DISPOSA 3MM       DBL-311",
      "code_information": [
        {
          "code": "3001371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 2990.1497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.6596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IPRISM IPC05",
      "code_information": [
        {
          "code": "3001669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAR-TIBIAL LOCKING      141205",
      "code_information": [
        {
          "code": "3002092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1493,
          "minimum": 313.6404,
          "maximum": 1083.4701,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 920.9496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 1.9X120 390-201",
      "code_information": [
        {
          "code": "3002152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1576,
          "minimum": 538.779,
          "maximum": 1143.7032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 972.1477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CEMENT-COMPACT VACUUM",
      "code_information": [
        {
          "code": "3002214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 99.5419,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.5996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           315.48",
      "code_information": [
        {
          "code": "3002244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 966.5961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.2      310.65",
      "code_information": [
        {
          "code": "3002246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 207.4253,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2049.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MINI DRILL AT2M-1813",
      "code_information": [
        {
          "code": "3002257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 1578.3975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1341.6379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145   03.010.104",
      "code_information": [
        {
          "code": "3002260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1668,
          "minimum": 570.2306,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1028.8975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    351.27",
      "code_information": [
        {
          "code": "3002270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3542,
          "minimum": 497.7095,
          "maximum": 2570.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2184.865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM      03.010.036",
      "code_information": [
        {
          "code": "3002274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3373,
          "minimum": 1153.1102,
          "maximum": 2447.7861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2080.6182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.060",
      "code_information": [
        {
          "code": "3002289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2190,
          "minimum": 521.0657,
          "maximum": 1589.283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1350.8905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5           310.23",
      "code_information": [
        {
          "code": "3002291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 937,
          "minimum": 320.3274,
          "maximum": 679.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 577.9838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM         310.19",
      "code_information": [
        {
          "code": "3002294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 949,
          "minimum": 324.4298,
          "maximum": 688.6893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 585.3859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MMX150MM  511.417",
      "code_information": [
        {
          "code": "3002302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1642,
          "minimum": 561.3421,
          "maximum": 1191.5994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1012.8595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2 ALL 1806-4200s",
      "code_information": [
        {
          "code": "3002305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1134,
          "minimum": 387.6748,
          "maximum": 822.9438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 699.5022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X180MM 1806-4270S",
      "code_information": [
        {
          "code": "3002306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 156.8202,
          "maximum": 882.4512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 750.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR        5091-206",
      "code_information": [
        {
          "code": "3002318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 63.3954,
          "maximum": 204.6474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.9503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-STEP DRILL         357.403",
      "code_information": [
        {
          "code": "3002361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3578,
          "minimum": 712.9202,
          "maximum": 2596.5546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2207.0714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.4     310.530",
      "code_information": [
        {
          "code": "3002365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1282,
          "minimum": 438.2708,
          "maximum": 930.3474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 790.7953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           1806-5020S",
      "code_information": [
        {
          "code": "3002379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1219,
          "minimum": 416.7333,
          "maximum": 884.6283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 751.9341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 03.113.024",
      "code_information": [
        {
          "code": "3002394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1440,
          "minimum": 492.2854,
          "maximum": 1045.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 888.2568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 03.113.023",
      "code_information": [
        {
          "code": "3002399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1440,
          "minimum": 492.2854,
          "maximum": 1045.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 888.2568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM 703542",
      "code_information": [
        {
          "code": "3002400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1284,
          "minimum": 438.9545,
          "maximum": 931.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 792.029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3MM 703541",
      "code_information": [
        {
          "code": "3002402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1335,
          "minimum": 201.8643,
          "maximum": 968.8095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 823.4881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5085-2-032",
      "code_information": [
        {
          "code": "3002403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM 5085-2-040",
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        {
          "code": "3002410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 1.7MM",
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        {
          "code": "3002760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1755,
          "minimum": 599.9728,
          "maximum": 1273.6035,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1082.563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO        1806-5000S",
      "code_information": [
        {
          "code": "3002772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1103,
          "minimum": 377.0769,
          "maximum": 1217.859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.38,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM     03.010.061",
      "code_information": [
        {
          "code": "3002776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2190,
          "minimum": 748.684,
          "maximum": 1589.283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1350.8905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM    03.010.101S",
      "code_information": [
        {
          "code": "3002777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 1578.3975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1341.6379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.6x",
      "code_information": [
        {
          "code": "3002779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2769,
          "minimum": 946.6238,
          "maximum": 2009.4633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1708.0438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL W/STOP ALL   324.15x",
      "code_information": [
        {
          "code": "3002780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2797,
          "minimum": 870.8526,
          "maximum": 2029.7829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1725.3155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.68",
      "code_information": [
        {
          "code": "3002782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2977,
          "minimum": 497.7095,
          "maximum": 2160.4089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1836.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 17MM    357.394",
      "code_information": [
        {
          "code": "3002785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4976,
          "minimum": 497.7095,
          "maximum": 3611.0832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3069.4207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM         700347",
      "code_information": [
        {
          "code": "3002791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1337,
          "minimum": 457.0733,
          "maximum": 970.2609,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 824.7218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1MM         702742",
      "code_information": [
        {
          "code": "3002793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1019,
          "minimum": 348.3603,
          "maximum": 739.4883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 628.5651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X110MM     310.35",
      "code_information": [
        {
          "code": "3002794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 921,
          "minimum": 314.8575,
          "maximum": 668.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.1142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER MINI       376900",
      "code_information": [
        {
          "code": "3002835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 618.9393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 9-9.5MM 5400-031-xxx",
      "code_information": [
        {
          "code": "3002951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1113,
          "minimum": 380.4956,
          "maximum": 807.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 686.5485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EXT ELECTRODE    E1551-6",
      "code_information": [
        {
          "code": "3002959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-TURBINATE INF SB2000SA",
      "code_information": [
        {
          "code": "3002962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1139,
          "minimum": 389.3841,
          "maximum": 826.5723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 702.5865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SERRATED STND SB4000SS",
      "code_information": [
        {
          "code": "3002963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 60.0588,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 801.8985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MYRINGOTOMY SPEAR TIP",
      "code_information": [
        {
          "code": "3003112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RAD 40 DEGREE 18-84006HR",
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        {
          "code": "3003122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1727,
          "minimum": 590.4006,
          "maximum": 1253.2839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.2913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RADNOID 18-84008",
      "code_information": [
        {
          "code": "3003123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1721,
          "minimum": 588.3494,
          "maximum": 1248.9297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1061.5902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RASP SAW       510037113",
      "code_information": [
        {
          "code": "3003127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 289.7281,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 683.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW MICR 9MM 2296-3-100s",
      "code_information": [
        {
          "code": "3003143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 178.1116,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 321.3762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG SAW 9X25 ALL 2296s",
      "code_information": [
        {
          "code": "3003147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 62.2832,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 321.3762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 5.5MMX18MM  KM 3-412",
      "code_information": [
        {
          "code": "3003150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 177.952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW GIGLI ROUND  2808-01",
      "code_information": [
        {
          "code": "3003172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 33.366,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.3904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HEX COATED 2.75   E1450X",
      "code_information": [
        {
          "code": "3003200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 2242.1952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-INF TURB 2.0  18-82040HR",
      "code_information": [
        {
          "code": "3003227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2469,
          "minimum": 844.0643,
          "maximum": 1791.7533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1522.9903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90Xxx    05.003.1xxS",
      "code_information": [
        {
          "code": "3003256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 967.0579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 384.9113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380HR",
      "code_information": [
        {
          "code": "3003258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1739,
          "minimum": 594.503,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1072.6935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS     519.xxxS",
      "code_information": [
        {
          "code": "3003292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 563.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 478.6717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CELL SAVER HI SP   CSP26x",
      "code_information": [
        {
          "code": "3003419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 777,
          "minimum": 265.629,
          "maximum": 563.8689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 479.2886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-SMARTMIX CTS    540176501",
      "code_information": [
        {
          "code": "3003433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-INTERNAL AR-1678-CP",
      "code_information": [
        {
          "code": "3003471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5500,
          "minimum": 554.9878,
          "maximum": 3991.35,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3392.6475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-UNIV X-ACT 11-2151-9",
      "code_information": [
        {
          "code": "3003472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 998,
          "minimum": 89.5321,
          "maximum": 724.2486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 615.6113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-WHISTLE CLEANING  000101",
      "code_information": [
        {
          "code": "3003605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.1898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT RND 2296-100-421",
      "code_information": [
        {
          "code": "3003756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 154.5958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL CUTTING 5300-010-901",
      "code_information": [
        {
          "code": "3003762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 278,
          "minimum": 95.0384,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND          277-10-423",
      "code_information": [
        {
          "code": "3003782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND CUT 2.4MM  5091-225",
      "code_information": [
        {
          "code": "3003786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 66.732,
          "maximum": 175.6194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.2765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT 1.6   277-10-xxx",
      "code_information": [
        {
          "code": "3003792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 347.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-WATERMELON      1607-2-35",
      "code_information": [
        {
          "code": "3003805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 708.4714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 384.9113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL   SP-7810",
      "code_information": [
        {
          "code": "3003812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1274,
          "minimum": 435.5358,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 785.8605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 2MM 5820-013-0xx",
      "code_information": [
        {
          "code": "3003829",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 300.294,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 787.7111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND 4.0MM    277-10-240",
      "code_information": [
        {
          "code": "3003855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.3062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 5MM     5820-013-050",
      "code_information": [
        {
          "code": "3003856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING BLUE   FL-601-97B",
      "code_information": [
        {
          "code": "3003905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 192.4556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT STERILE MAS PLIF",
      "code_information": [
        {
          "code": "3003914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 5832.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1759.8588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ARCH 6.5  80320",
      "code_information": [
        {
          "code": "3004042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO DBL 5MM PAL-505LL",
      "code_information": [
        {
          "code": "3004047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 86.1955,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY PREMATURE",
      "code_information": [
        {
          "code": "3004048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY NEONATAL",
      "code_information": [
        {
          "code": "3004049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERPAY INFANT",
      "code_information": [
        {
          "code": "3004051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 411.514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-308LS",
      "code_information": [
        {
          "code": "3004052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 537.018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 456.4653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CURVED 100MM 20G 10.0M",
      "code_information": [
        {
          "code": "3004190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX FEM TFA-022-25",
      "code_information": [
        {
          "code": "3004225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 441.9513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 375.6586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX       TFA02025",
      "code_information": [
        {
          "code": "3004226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 375.6586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 27FR 96370-027",
      "code_information": [
        {
          "code": "3004235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1777,
          "minimum": 607.4939,
          "maximum": 1289.5689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1096.1336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-5FR RAD PIGTAIL 5RPS110-N",
      "code_information": [
        {
          "code": "3004842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 364,
          "minimum": 124.4388,
          "maximum": 1145.0099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.5316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TACKER DELIVERY OMS-TTS",
      "code_information": [
        {
          "code": "3005077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3218,
          "minimum": 870.8526,
          "maximum": 2335.3026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1985.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHLOANGIOGRAM   20018-010",
      "code_information": [
        {
          "code": "3005234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 613,
          "minimum": 110.6639,
          "maximum": 444.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 378.126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 24Fr 5CC 265724",
      "code_information": [
        {
          "code": "3005414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 574.4513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.0949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3WAY         73022L",
      "code_information": [
        {
          "code": "3005435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 1478.6699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-PASSER            8591-38",
      "code_information": [
        {
          "code": "3006601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1761.7248,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 34FR-46FR ALL",
      "code_information": [
        {
          "code": "3007230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 442.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 376.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 36FR-46FR  TF36460",
      "code_information": [
        {
          "code": "3007235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 442.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 376.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP         AA01",
      "code_information": [
        {
          "code": "3007600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-ACU-DISPO      DCFT2",
      "code_information": [
        {
          "code": "3007601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 1595.4509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP,MULTI-PIN LG 390.004",
      "code_information": [
        {
          "code": "3008494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4727,
          "minimum": 1615.9952,
          "maximum": 3430.3839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2915.8263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-NV DSC & IN-LINE ACTIVATO",
      "code_information": [
        {
          "code": "3008690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 432.0897,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LAPRA-TY ABS SUTURE XC200",
      "code_information": [
        {
          "code": "3008699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 777,
          "minimum": 52.2734,
          "maximum": 563.8689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 479.2886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIPS-HEM-O-LOC         544230",
      "code_information": [
        {
          "code": "3008728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.9834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK LG       544240",
      "code_information": [
        {
          "code": "3008730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.1139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK XL       544250",
      "code_information": [
        {
          "code": "3008731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X3/8 XA6062",
      "code_information": [
        {
          "code": "3009659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 871,
          "minimum": 297.7643,
          "maximum": 2382.3324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 537.272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR ACCU-FLO 82-1504",
      "code_information": [
        {
          "code": "3009774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 387.3329,
          "maximum": 2246.0879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 698.8854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONSTAVAC-CBC II    225-28-614",
      "code_information": [
        {
          "code": "3009792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1463,
          "minimum": 83.415,
          "maximum": 1061.6991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 902.4442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR BOVIE DISP 301538",
      "code_information": [
        {
          "code": "3009842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 155.708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR HIGH   26176LD/10",
      "code_information": [
        {
          "code": "3009843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 1074.9413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 172.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNULATED",
      "code_information": [
        {
          "code": "3009845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1933,
          "minimum": 660.8248,
          "maximum": 1402.7781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1192.3614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNUL 3.8MM",
      "code_information": [
        {
          "code": "3009850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 50.049,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1109.7042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-SILICONE RETRACTOR",
      "code_information": [
        {
          "code": "3009851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 158.4885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-DISPOSABLE ACTIVE DAC",
      "code_information": [
        {
          "code": "3009853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 1787.3054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.8008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-8 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 187.2306,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 206.8245,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.8008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 10191.6447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.0725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 252.5436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.6621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-30 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 428,
          "minimum": 146.3182,
          "maximum": 310.5996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 264.0097,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MERCEDES     PAL-506LL",
      "code_information": [
        {
          "code": "3010053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 2360.0884,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS ALL SZS   681xx",
      "code_information": [
        {
          "code": "3010076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 551,
          "minimum": 188.3675,
          "maximum": 2007.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 339.8816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT ALL SZ",
      "code_information": [
        {
          "code": "3010079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 1508.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL 1X4  2111-04-077",
      "code_information": [
        {
          "code": "3010088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2712,
          "minimum": 927.1375,
          "maximum": 3166.9895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1672.8836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL ALL  2111-08-07x",
      "code_information": [
        {
          "code": "3010090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5695,
          "minimum": 265.2597,
          "maximum": 4132.8615,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3512.9323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X20 657320",
      "code_information": [
        {
          "code": "3010104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 840.1429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X40 657340",
      "code_information": [
        {
          "code": "3010107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 840.1429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DUBIN              8390",
      "code_information": [
        {
          "code": "3010215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 494.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION         BID30",
      "code_information": [
        {
          "code": "3010259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 890,
          "minimum": 265.8158,
          "maximum": 645.873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 548.992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE TISSUE REMOVAL",
      "code_information": [
        {
          "code": "3010310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1901.3059,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LAPARSCOP PLUME FILTER",
      "code_information": [
        {
          "code": "3010330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 198,
          "minimum": 67.6892,
          "maximum": 5379.1553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 122.1353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VAGINAL POSITIONING",
      "code_information": [
        {
          "code": "3010598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2367,
          "minimum": 809.1941,
          "maximum": 1717.7319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1460.0721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-BLUNT TIP 5 PK BTD05",
      "code_information": [
        {
          "code": "3010867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1 5901-1126",
      "code_information": [
        {
          "code": "3011002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 207.4253,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.6824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHAN W/TROCAR ALL SIZES",
      "code_information": [
        {
          "code": "3011730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 199,
          "minimum": 43.3758,
          "maximum": 144.4143,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 122.7522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT HUBLESS ALL SZS",
      "code_information": [
        {
          "code": "3011780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.1139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-MINI CHEST 500     16400",
      "code_information": [
        {
          "code": "3011787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1139,
          "minimum": 389.3841,
          "maximum": 826.5723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 702.5865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FECAL MANAGEMENT 418000",
      "code_information": [
        {
          "code": "3011910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1469,
          "minimum": 36.1465,
          "maximum": 1066.0533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 906.1453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FECAL MANAGEMENT 411108",
      "code_information": [
        {
          "code": "3011911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 120.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.0949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-HIP W/POUCHES DYNJP8201",
      "code_information": [
        {
          "code": "3011920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 217,
          "minimum": 74.1847,
          "maximum": 157.4769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.8554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BEACH CHAIR SHOULDER",
      "code_information": [
        {
          "code": "3011922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 257,
          "minimum": 87.8593,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.5292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BARIATRIC      DYNJP3105",
      "code_information": [
        {
          "code": "3011926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 77.9452,
          "maximum": 271.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.6407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-DOUBLE 44X66     ORS 320",
      "code_information": [
        {
          "code": "3011927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 301.0204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 12MM CD004",
      "code_information": [
        {
          "code": "3011949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 32.2538,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE 3M SHORT   6661EZ",
      "code_information": [
        {
          "code": "3011953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 148.4787,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-ISO IOBAN HIP       6617",
      "code_information": [
        {
          "code": "3011959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 200.196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 164.6976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INTESTINAL 18X18.5 ISO1003",
      "code_information": [
        {
          "code": "3011960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 360,
          "minimum": 123.0713,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.0642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 10MM CD001",
      "code_information": [
        {
          "code": "3011961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 44.488,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI     326088-0000-000",
      "code_information": [
        {
          "code": "3011985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 155.1519,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI FULL         306070",
      "code_information": [
        {
          "code": "3011987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 279,
          "minimum": 95.3803,
          "maximum": 328.6551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 172.0998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER           ORS-400",
      "code_information": [
        {
          "code": "3011995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 591,
          "minimum": 33.366,
          "maximum": 428.8887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 364.5554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERI IRRIGATION    1016",
      "code_information": [
        {
          "code": "3012018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 68.9564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE HAND   DYNJP8005",
      "code_information": [
        {
          "code": "3012025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 89.9868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.4888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR GLASSCOCK  S-1000",
      "code_information": [
        {
          "code": "3012051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 266.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 191.8388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GENTLE CARE SURG 12-1",
      "code_information": [
        {
          "code": "3012060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 480,
          "minimum": 164.0951,
          "maximum": 348.336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.0856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-TOPIFOAM      5710-30",
      "code_information": [
        {
          "code": "3012080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 57.2783,
          "maximum": 216.9843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED ASNIS III",
      "code_information": [
        {
          "code": "3012111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1063.8193,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.5MM  702450",
      "code_information": [
        {
          "code": "3012114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 673.4371,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-HEX 1.1X67       15-1723",
      "code_information": [
        {
          "code": "3012115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1211,
          "minimum": 413.9983,
          "maximum": 878.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 746.9993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3012118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 966.5961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST ASNIS III 6.5MM",
      "code_information": [
        {
          "code": "3012151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN 4.0MM W/AO",
      "code_information": [
        {
          "code": "3012152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5392,
          "minimum": 813.0182,
          "maximum": 3912.9744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3326.0282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SHAFT-AO 2.6MMX122MM",
      "code_information": [
        {
          "code": "3012186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           310.48",
      "code_information": [
        {
          "code": "3012201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1176,
          "minimum": 402.0331,
          "maximum": 853.4232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 725.4097,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1806-5010S",
      "code_information": [
        {
          "code": "3012206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1103,
          "minimum": 377.0769,
          "maximum": 800.4471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.38,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 03.6MMX122MM",
      "code_information": [
        {
          "code": "3012207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1378,
          "minimum": 471.0898,
          "maximum": 1000.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 850.0124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 13.0MM CANNULATED",
      "code_information": [
        {
          "code": "3012314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4464,
          "minimum": 540.5292,
          "maximum": 3239.5248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2753.5961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         MS-DCR20",
      "code_information": [
        {
          "code": "3012321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 959.2725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 676.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 LG 120MM",
      "code_information": [
        {
          "code": "3012325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1725,
          "minimum": 589.7169,
          "maximum": 1251.8325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1064.0576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 315.28",
      "code_information": [
        {
          "code": "3012330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1374,
          "minimum": 469.7223,
          "maximum": 997.1118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X40   2274-12-000",
      "code_information": [
        {
          "code": "3012344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1940,
          "minimum": 586.6855,
          "maximum": 1407.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1196.6793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5          MS-DC35",
      "code_information": [
        {
          "code": "3012346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1055,
          "minimum": 360.6674,
          "maximum": 765.6135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 650.7715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.201",
      "code_information": [
        {
          "code": "3012355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 912,
          "minimum": 311.7808,
          "maximum": 661.8384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 562.5626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL               310.28",
      "code_information": [
        {
          "code": "3012356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 784.6571,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 599.5733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.431",
      "code_information": [
        {
          "code": "3012357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1411,
          "minimum": 482.3713,
          "maximum": 1023.9627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 870.3683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL            32-486265",
      "code_information": [
        {
          "code": "3012365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 769,
          "minimum": 262.8941,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 474.3538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL         5820-107-530",
      "code_information": [
        {
          "code": "3012374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 1340.201,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           AT2M-L1813",
      "code_information": [
        {
          "code": "3012378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2410,
          "minimum": 823.8943,
          "maximum": 1748.937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1486.5965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED   310.634",
      "code_information": [
        {
          "code": "3012380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1648.8267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 5.0MM",
      "code_information": [
        {
          "code": "3012381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1648.8267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM 60-19340",
      "code_information": [
        {
          "code": "3012401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1102,
          "minimum": 376.7351,
          "maximum": 799.7214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 679.7632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHRT 3.2 03.010.103S",
      "code_information": [
        {
          "code": "3012406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1666,
          "minimum": 569.5469,
          "maximum": 1209.0162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1027.6638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL 5MM     DBL-511",
      "code_information": [
        {
          "code": "3012461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.6596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL LOOP      B0512",
      "code_information": [
        {
          "code": "3012465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 51.1612,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X2.75 E1455",
      "code_information": [
        {
          "code": "3012472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X4  E1455-4",
      "code_information": [
        {
          "code": "3012473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 762.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-208",
      "code_information": [
        {
          "code": "3012474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1372,
          "minimum": 469.0386,
          "maximum": 995.6604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 846.3113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EZ CLEAN CAUTERY TIP",
      "code_information": [
        {
          "code": "3012505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 43.3758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.3096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE MOD     0014AM",
      "code_information": [
        {
          "code": "3012507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.1139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BOVIE RED      E7507",
      "code_information": [
        {
          "code": "3012513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 231.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK  E2773-45",
      "code_information": [
        {
          "code": "3012520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 61.7271,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.2244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MRI CONDITIONAL DISP",
      "code_information": [
        {
          "code": "3012521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 1396.9232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LIGASURE      LS1037",
      "code_information": [
        {
          "code": "3012535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2512,
          "minimum": 858.7645,
          "maximum": 1822.9584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1549.5146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 2CHAN 8227410",
      "code_information": [
        {
          "code": "3012585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1545,
          "minimum": 528.1812,
          "maximum": 1121.2065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 953.0255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-RADIUS LOOP    R1010",
      "code_information": [
        {
          "code": "3012596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 41.7075,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 6.5\\\" 0014M",
      "code_information": [
        {
          "code": "3012611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 54.4275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.2634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-TEFLON 6 1/2 BLADE",
      "code_information": [
        {
          "code": "3012613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDCAP-ROUND X-CORE    5960200",
      "code_information": [
        {
          "code": "3012635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4702,
          "minimum": 1037.1265,
          "maximum": 3412.2414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2900.4052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3012680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2877,
          "minimum": 983.5452,
          "maximum": 2974.5789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1774.6631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVACUATOR-UROVAC       730-125",
      "code_information": [
        {
          "code": "3012699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 100.098,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVAC-SAF-T-VAC         ST9000S",
      "code_information": [
        {
          "code": "3012723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 667.8761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.0321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-GLUE             540133500",
      "code_information": [
        {
          "code": "3012805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 199.0838,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXCISOR-BIOPSY CONE",
      "code_information": [
        {
          "code": "3012815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-DIALYSIS CATH  415612",
      "code_information": [
        {
          "code": "3012854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1265,
          "minimum": 432.459,
          "maximum": 918.0105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 780.3089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTRACTOR-TRIGEN DISP 71631320",
      "code_information": [
        {
          "code": "3012895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.5996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBE-VIPERSLIDE VPR-SLD2",
      "code_information": [
        {
          "code": "3012925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.6824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 1X6        007976",
      "code_information": [
        {
          "code": "3012991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 1153.3514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 4\\\"X4\\\"       007836",
      "code_information": [
        {
          "code": "3012993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2074,
          "minimum": 709.0277,
          "maximum": 7269.3392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1279.3365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 200M",
      "code_information": [
        {
          "code": "3013060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2420,
          "minimum": 827.313,
          "maximum": 1756.194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1492.7649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 365M",
      "code_information": [
        {
          "code": "3013061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2010,
          "minimum": 687.1484,
          "maximum": 1473.1089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1239.8584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 550M",
      "code_information": [
        {
          "code": "3013062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2649,
          "minimum": 905.6,
          "maximum": 2081.4823,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1634.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 1000M",
      "code_information": [
        {
          "code": "3013063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3743,
          "minimum": 1066.0437,
          "maximum": 2716.2951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2308.8508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-COUDE HEYMAN   021300",
      "code_information": [
        {
          "code": "3013087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1917,
          "minimum": 655.3549,
          "maximum": 1391.1669,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1182.4919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-HEYMAN         021100",
      "code_information": [
        {
          "code": "3013090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1718,
          "minimum": 365.3577,
          "maximum": 1246.7526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1059.7397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPER-          AR-7237-7",
      "code_information": [
        {
          "code": "3013107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 1783.4127,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 3  AR-7227-01",
      "code_information": [
        {
          "code": "3013134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 238.7553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 4  AR-7230-01",
      "code_information": [
        {
          "code": "3013135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 43.3758,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-HEPA BACTERIA 00182",
      "code_information": [
        {
          "code": "3013160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.1139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PED OXYKID W/7' TUBING",
      "code_information": [
        {
          "code": "3013161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 75.6296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.4318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-INSUFFLATION BULB",
      "code_information": [
        {
          "code": "3013164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 131.7957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.8909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP     1599-05",
      "code_information": [
        {
          "code": "3013203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 237,
          "minimum": 81.022,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 146.1923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-PIRANHA 3FR     505-160",
      "code_information": [
        {
          "code": "3013317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2055,
          "minimum": 69.5125,
          "maximum": 1491.3135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1267.6165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW      000300s",
      "code_information": [
        {
          "code": "3013320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 90.7125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GEL-PROLARYN          8602M0K5",
      "code_information": [
        {
          "code": "3013462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4034,
          "minimum": 1379.0828,
          "maximum": 52874.5441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2488.3527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3014234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 6.5 DRILL",
      "code_information": [
        {
          "code": "3014235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 804.9827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-AR-8737-01",
      "code_information": [
        {
          "code": "3014239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3014272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 3372.7465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-DBX MIX 2.5CC     058025",
      "code_information": [
        {
          "code": "3014900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2432,
          "minimum": 831.4153,
          "maximum": 2273.3368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1500.167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-HELI-FX            SG-64",
      "code_information": [
        {
          "code": "3016110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 107.8834,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-WIRE .035      WS-0906ST",
      "code_information": [
        {
          "code": "3016121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2MM           292.65",
      "code_information": [
        {
          "code": "3016129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 552,
          "minimum": 188.7094,
          "maximum": 400.5864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 340.4984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K SMOOTH TIP AGK16100",
      "code_information": [
        {
          "code": "3016134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 606.7051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 192.4556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-3.2       03.010.115",
      "code_information": [
        {
          "code": "3016135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1091,
          "minimum": 372.9746,
          "maximum": 791.7387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 672.9779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K W/OLIVE STOP",
      "code_information": [
        {
          "code": "3016136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 263.5914,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 869.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-SUT GABBY-FRATER SUT 013",
      "code_information": [
        {
          "code": "3016153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 695.125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 172.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP AR894301",
      "code_information": [
        {
          "code": "3016164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-HALTER DISP 08143101",
      "code_information": [
        {
          "code": "3016272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 118,
          "minimum": 40.3401,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.7877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ADHESIVE 4\\\" WHITE",
      "code_information": [
        {
          "code": "3016326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 58022.9179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1963",
      "code_information": [
        {
          "code": "3016347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1292,
          "minimum": 114.5566,
          "maximum": 937.6044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 796.9637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOVAC-400ML LG   2550-004-10",
      "code_information": [
        {
          "code": "3016381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 1215.6346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.0701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-HYDRODEB     1914001",
      "code_information": [
        {
          "code": "3016387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2186,
          "minimum": 747.3166,
          "maximum": 1586.3802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1348.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM SNGL PK 33508G",
      "code_information": [
        {
          "code": "3016420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 2308.9272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM DOUBLE  3384-4",
      "code_information": [
        {
          "code": "3016425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 434,
          "minimum": 148.3693,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.7107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 2X4 2082",
      "code_information": [
        {
          "code": "3016450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 704.6547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 4X4 2083",
      "code_information": [
        {
          "code": "3016451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1255,
          "minimum": 429.0404,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 774.1405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-J CAUTERY     60-5272-232",
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        {
          "code": "3016500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.0155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-ULTRASLING III XLG",
      "code_information": [
        {
          "code": "3017486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 347.5625,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 266.477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUTTLE-ACCU PASS SUTURE 70DEG",
      "code_information": [
        {
          "code": "3019705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1334,
          "minimum": 456.0477,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 822.8712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-EVERGRIP LF  EVERGRIP61",
      "code_information": [
        {
          "code": "3019748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 322,
          "minimum": 110.0805,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FDG",
      "code_information": [
        {
          "code": "3019810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2674,
          "minimum": 914.1466,
          "maximum": 1940.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1649.4435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGL",
      "code_information": [
        {
          "code": "3019813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 914.1466,
          "maximum": 1940.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1649.4435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGD",
      "code_information": [
        {
          "code": "3019815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3010,
          "minimum": 1029.0132,
          "maximum": 2184.357,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1856.7034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-PEELAWAY 16F",
      "code_information": [
        {
          "code": "3019878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 615,
          "minimum": 210.2469,
          "maximum": 446.3055,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.3597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT 9FR 3 1/2 PI93",
      "code_information": [
        {
          "code": "3019879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 381,
          "minimum": 130.2505,
          "maximum": 276.4917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.0179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2MM 500373",
      "code_information": [
        {
          "code": "3020202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 709,
          "minimum": 242.3822,
          "maximum": 589.466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 437.3431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPER DISTRACTOR FF904SB",
      "code_information": [
        {
          "code": "3020203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1060,
          "minimum": 362.3768,
          "maximum": 769.242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 653.8557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 17L 96550",
      "code_information": [
        {
          "code": "3020800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 515,
          "minimum": 176.0604,
          "maximum": 2737.6803,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 317.6752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-I RING PUPIL 587000",
      "code_information": [
        {
          "code": "3020804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1251,
          "minimum": 427.6729,
          "maximum": 907.8507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 771.6731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL VISULIZATION",
      "code_information": [
        {
          "code": "3020806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUG 03.804.522S",
      "code_information": [
        {
          "code": "3020807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 859,
          "minimum": 56.7222,
          "maximum": 623.3763,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 529.8699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SCOPE WARMER TM500",
      "code_information": [
        {
          "code": "3020808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 250.8011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENTI SCAN IV DISP 177-092",
      "code_information": [
        {
          "code": "3020810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 451,
          "minimum": 154.1811,
          "maximum": 3042.9792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 278.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESSORY 700     72401850",
      "code_information": [
        {
          "code": "3020811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5472,
          "minimum": 1870.6845,
          "maximum": 3971.0304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3375.3758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COAG  CSP208",
      "code_information": [
        {
          "code": "3020850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 2343.4054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DILATOR NVM5       2029950",
      "code_information": [
        {
          "code": "3020915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 757.4082,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2957.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-19",
      "code_information": [
        {
          "code": "3020920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 1248.4445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 840.1429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-21",
      "code_information": [
        {
          "code": "3020922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2245,
          "minimum": 497.7095,
          "maximum": 1629.1965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1384.817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC     96530-017",
      "code_information": [
        {
          "code": "3020928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1177,
          "minimum": 402.3749,
          "maximum": 2227.1805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 726.0266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IV MAXCESS         3240060",
      "code_information": [
        {
          "code": "3020969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8227,
          "minimum": 2812.5222,
          "maximum": 8921.5123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5074.7838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX PT STARTER  50-0071",
      "code_information": [
        {
          "code": "3021029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2289,
          "minimum": 782.5287,
          "maximum": 2001.4039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1411.9582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHUNT NONINVASIVE  9733605",
      "code_information": [
        {
          "code": "3021032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3599,
          "minimum": 895.321,
          "maximum": 2611.7943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2220.0252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 4ML 1501262",
      "code_information": [
        {
          "code": "3021034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1610,
          "minimum": 264.7036,
          "maximum": 1168.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 993.1205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH&BOOT 3550-80",
      "code_information": [
        {
          "code": "3021046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 476,
          "minimum": 162.7277,
          "maximum": 1362.445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 293.6182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERITONEAL DIALYSIS 278006",
      "code_information": [
        {
          "code": "3021065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1150,
          "minimum": 96.2053,
          "maximum": 834.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 709.3718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHOULDER CANNULA 5CM  9718",
      "code_information": [
        {
          "code": "3021080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 974.8433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-URO MAX HI PRESURE 225-136",
      "code_information": [
        {
          "code": "3021090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1753,
          "minimum": 599.2891,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1081.3293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXTRACTION GTG14",
      "code_information": [
        {
          "code": "3021113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4570,
          "minimum": 1562.3224,
          "maximum": 3316.449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2818.9816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X12MM 663812",
      "code_information": [
        {
          "code": "3021130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 951,
          "minimum": 67.2881,
          "maximum": 690.1407,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 586.6196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE,SLIT 2.4MM 45 DEGREE",
      "code_information": [
        {
          "code": "3021161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 1114.4244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 162.2302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-GRAFT ACL 10MM    232110",
      "code_information": [
        {
          "code": "3021173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2004,
          "minimum": 271.3768,
          "maximum": 1454.3028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1236.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT CLEAR CUT 2.4",
      "code_information": [
        {
          "code": "3021199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 58.9466,
          "maximum": 354.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 301.0204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDE PORT 1.1    78-2010",
      "code_information": [
        {
          "code": "3021203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 937.5846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-TUIP             880-217",
      "code_information": [
        {
          "code": "3021220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 749,
          "minimum": 256.0568,
          "maximum": 667.8761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 462.0169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE ALL AR-4000Ss",
      "code_information": [
        {
          "code": "3021225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE         AR-4068's",
      "code_information": [
        {
          "code": "3021227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 4811.9333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDEPORT SAFETY 1.0MM",
      "code_information": [
        {
          "code": "3021241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 110.7642,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.8578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINER-SZ25/36MM RL 12-105995",
      "code_information": [
        {
          "code": "3021635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4400,
          "minimum": 1504.2054,
          "maximum": 8241.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2714.118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-IMPACT         LF4318",
      "code_information": [
        {
          "code": "3021733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2708,
          "minimum": 145.1421,
          "maximum": 1965.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1670.4163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-DRAINAGE LOCKABLE 50-7245",
      "code_information": [
        {
          "code": "3021737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.9965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 26FR      880-214",
      "code_information": [
        {
          "code": "3021821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 134.0201,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 428.0904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-DISPOSA ALL",
      "code_information": [
        {
          "code": "3021826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.6596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-ELECTRODE 24FR   WA22037C",
      "code_information": [
        {
          "code": "3021880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1483,
          "minimum": 326.4307,
          "maximum": 1076.2131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 914.7811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WIRE SNARE 8-14515",
      "code_information": [
        {
          "code": "3021881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 1048.8046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 362.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-MS SSEP NEEDLE  8050315",
      "code_information": [
        {
          "code": "3022945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5246,
          "minimum": 1793.4231,
          "maximum": 3807.0222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3235.9689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE EMG 8050015",
      "code_information": [
        {
          "code": "3022950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE MEP/EMG",
      "code_information": [
        {
          "code": "3022955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 4022.8274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3131.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SINGLE PORT PAL 240LS",
      "code_information": [
        {
          "code": "3023177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 4022.8274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 491.0086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY STEALTH  9733068",
      "code_information": [
        {
          "code": "3027284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4784,
          "minimum": 117.8932,
          "maximum": 3471.7488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2950.9865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY TRU CUT 2N2700s",
      "code_information": [
        {
          "code": "3027285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 153.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.7711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY CUT      4418-16",
      "code_information": [
        {
          "code": "3027295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 413.7384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DEFLUX 23GX3.7FX350mm",
      "code_information": [
        {
          "code": "3027296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 744,
          "minimum": 254.3475,
          "maximum": 539.9208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 458.9327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DISP INSUF      S100000",
      "code_information": [
        {
          "code": "3027310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 482,
          "minimum": 45.0441,
          "maximum": 349.7874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.3193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ELECTRODE COATD E1465-6",
      "code_information": [
        {
          "code": "3027313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 399.8359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ENDOPATH INSUFF   PN120",
      "code_information": [
        {
          "code": "3027315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 719,
          "minimum": 245.8008,
          "maximum": 521.7783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 443.5116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL       105-1314",
      "code_information": [
        {
          "code": "3027318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 88.4199,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-20      G00013",
      "code_information": [
        {
          "code": "3027330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 230.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FORAMEN 20G      041829",
      "code_information": [
        {
          "code": "3027344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 301.1655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 255.9907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-6 DJ6011X",
      "code_information": [
        {
          "code": "3027346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 292,
          "minimum": 99.8245,
          "maximum": 216.879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 180.1187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR        1650050",
      "code_information": [
        {
          "code": "3027347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 390,
          "minimum": 125.6786,
          "maximum": 283.023,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 240.5695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSULATED EDGE   E1465B",
      "code_information": [
        {
          "code": "3027368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 77.2615,
          "maximum": 719.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TR-CRON 2-0 STR W/10 SW",
      "code_information": [
        {
          "code": "3027402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 437,
          "minimum": 149.3949,
          "maximum": 348.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 269.5613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR W/SHEATH",
      "code_information": [
        {
          "code": "3027403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 626,
          "minimum": 214.0074,
          "maximum": 454.2882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 386.145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OPUS SPEEDSTITCH",
      "code_information": [
        {
          "code": "3027425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 397,
          "minimum": 135.7203,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 244.8875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OCTRODE 6\\\"         1116",
      "code_information": [
        {
          "code": "3027430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODESSECTION   N103A",
      "code_information": [
        {
          "code": "3027433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 690,
          "minimum": 235.8868,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 425.623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION      AR-13991N",
      "code_information": [
        {
          "code": "3027443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 440.9873,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SIDEKICK 21GA 14.6\\\"",
      "code_information": [
        {
          "code": "3027445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 793,
          "minimum": 207.4253,
          "maximum": 575.4801,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 489.1581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODISSECTION   E1xxx",
      "code_information": [
        {
          "code": "3027520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 795,
          "minimum": 45.0441,
          "maximum": 576.9315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 490.3918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-W/BASEPLATE BSDN-18-7.0",
      "code_information": [
        {
          "code": "3027587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 722.3739,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 5MM  VS101005",
      "code_information": [
        {
          "code": "3027591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1299,
          "minimum": 444.0825,
          "maximum": 942.6843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 801.2817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VERSASTEP 14GA VS150000",
      "code_information": [
        {
          "code": "3027593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 600,
          "minimum": 205.1189,
          "maximum": 680.6664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 370.107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TROCAR 12MM VS101000s",
      "code_information": [
        {
          "code": "3027595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1224,
          "minimum": 418.4426,
          "maximum": 888.2568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 755.0183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-WILSON PENILE IMPLANT",
      "code_information": [
        {
          "code": "3029175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2504,
          "minimum": 856.0296,
          "maximum": 1817.1528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1544.5799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FENWAL TRANSFER 4R2014",
      "code_information": [
        {
          "code": "3029199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 373.1431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-EXTREMITY      DYNJ31779F",
      "code_information": [
        {
          "code": "3029200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 671,
          "minimum": 75.6296,
          "maximum": 486.9447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 413.903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAGNETIC DRAPE    31140562",
      "code_information": [
        {
          "code": "3029201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 1966.3696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.8909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY ELITE VIAL     LC3001",
      "code_information": [
        {
          "code": "3029202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3536,
          "minimum": 1208.8341,
          "maximum": 2566.0752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2181.1639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SENSA TRAC M8275057/10",
      "code_information": [
        {
          "code": "3029214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 196.6647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-PERFUSION CUSTOM  CK0226R",
      "code_information": [
        {
          "code": "3029252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3994,
          "minimum": 145.1421,
          "maximum": 2898.4458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2463.6789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SHOULDER ARTHROSCOP 29367",
      "code_information": [
        {
          "code": "3029266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 189.4077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.9965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SINUS KENNEDY      400422",
      "code_information": [
        {
          "code": "3029267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 656.198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-TOTAL JOINT    DYNJ31778A",
      "code_information": [
        {
          "code": "3029268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1180,
          "minimum": 99.5419,
          "maximum": 856.326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 727.8771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM     440400",
      "code_information": [
        {
          "code": "3029278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAK-CONFIDENCE PLUS",
      "code_information": [
        {
          "code": "3029292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HAND DYNJ52365",
      "code_information": [
        {
          "code": "3029301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 636,
          "minimum": 217.4261,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 392.3134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VITRECTOMY CENTURION",
      "code_information": [
        {
          "code": "3029308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 966.5961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH  82-151x",
      "code_information": [
        {
          "code": "3029345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1307,
          "minimum": 446.8174,
          "maximum": 948.4899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 806.2164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SMART STITCH PERFECT",
      "code_information": [
        {
          "code": "3029347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 917,
          "minimum": 265.8158,
          "maximum": 665.4669,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 565.6469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE           032401",
      "code_information": [
        {
          "code": "3029348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 396.4993,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-HEMA KNITTED   HGK75/75P",
      "code_information": [
        {
          "code": "3029426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1254,
          "minimum": 428.6985,
          "maximum": 7405.5837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 773.5236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-ACTIVA 2.5 INTELLIDOSE",
      "code_information": [
        {
          "code": "3029528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.6762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-DISPOSABLE  26-1221",
      "code_information": [
        {
          "code": "3029529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 2058.1261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1651.9109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORIENTATION 2307-71-000",
      "code_information": [
        {
          "code": "3029762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 721.3458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 613.1439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-NAVIGATION 6007-003-150",
      "code_information": [
        {
          "code": "3029767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 150.7031,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 576.7501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ARM ELEVATION 79-90500",
      "code_information": [
        {
          "code": "3029771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 520.5096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KNEE PROCEDURE TRACK 10712",
      "code_information": [
        {
          "code": "3029811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 180.7325,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 840.1429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-DEMAYO LEG 110550",
      "code_information": [
        {
          "code": "3029813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 533.856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 200.4746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BREAKAWAY GUIDE 2.5MM",
      "code_information": [
        {
          "code": "3029840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2605,
          "minimum": 603.9246,
          "maximum": 1890.4485,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1606.8812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144110",
      "code_information": [
        {
          "code": "3029841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1086,
          "minimum": 371.2652,
          "maximum": 788.1102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 669.8937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DHS GUIDE          900.723",
      "code_information": [
        {
          "code": "3029855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 658,
          "minimum": 224.9471,
          "maximum": 551.6512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-POSITIONING EZ CLIP 2MM",
      "code_information": [
        {
          "code": "3029858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1123,
          "minimum": 383.9142,
          "maximum": 1046.0241,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.7169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-FLUTED HEADLESS 7650-2038A",
      "code_information": [
        {
          "code": "3029885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1881,
          "minimum": 616.7149,
          "maximum": 1365.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1160.2854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE              357.399",
      "code_information": [
        {
          "code": "3029929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1109,
          "minimum": 379.1281,
          "maximum": 3924.9538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 684.0811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PINS-GUIDE 7.3         900.726",
      "code_information": [
        {
          "code": "3030050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 943,
          "minimum": 207.4253,
          "maximum": 684.3351,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 581.6848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1\\\"",
      "code_information": [
        {
          "code": "3033301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 48,
          "minimum": 16.4095,
          "maximum": 34.8336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 29.6086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 16FR 10ML",
      "code_information": [
        {
          "code": "3033303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F SCREWS 45-80040",
      "code_information": [
        {
          "code": "3033883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1582.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-LARGE SOFT       PCP40",
      "code_information": [
        {
          "code": "3033952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POINTER-TRACER         9733423",
      "code_information": [
        {
          "code": "3034140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3396,
          "minimum": 175.7276,
          "maximum": 2464.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2094.8056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-BIOPSY             AUR-BP",
      "code_information": [
        {
          "code": "3034190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 316,
          "minimum": 108.0293,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-GEL HAND            C8XX2",
      "code_information": [
        {
          "code": "3034194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2435.9209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOCATCH-II W/POUCH ALL 173's",
      "code_information": [
        {
          "code": "3034302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2140,
          "minimum": 497.7095,
          "maximum": 1552.998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1320.0483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD ENTERAL 7FR 350CM",
      "code_information": [
        {
          "code": "3034510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 966.5961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NEUROVISION M5   2012021",
      "code_information": [
        {
          "code": "3034522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 592.2465,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 2.3MM 6.9FR 300CM",
      "code_information": [
        {
          "code": "3034891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 8367.0806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-WOUND GELPOINT CNGL2",
      "code_information": [
        {
          "code": "3038330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 19421.7925,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2609.8712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-PAIN ONQ 400ML    PM028-A",
      "code_information": [
        {
          "code": "3038635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1884,
          "minimum": 644.0734,
          "maximum": 3289.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1162.136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-KNOT 2-0 FIBERWIRE",
      "code_information": [
        {
          "code": "3038667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 99.5419,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 804.9827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-DEKNATEL 4.4      MDP-44",
      "code_information": [
        {
          "code": "3038930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 398,
          "minimum": 136.0622,
          "maximum": 525.5145,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 245.5043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GREEN    ECR45G",
      "code_information": [
        {
          "code": "3039881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1406,
          "minimum": 207.4253,
          "maximum": 1020.3342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 867.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO LINEAR       TR35B",
      "code_information": [
        {
          "code": "3039888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 838,
          "minimum": 47.2685,
          "maximum": 608.1366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 516.9161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-TUBING         RF10210",
      "code_information": [
        {
          "code": "3039889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 80.0784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.4318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W564",
      "code_information": [
        {
          "code": "3039894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 104.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W332",
      "code_information": [
        {
          "code": "3039896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 239.6791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN        XR30G",
      "code_information": [
        {
          "code": "3039899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 431,
          "minimum": 147.3438,
          "maximum": 312.7767,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.8602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH       170056",
      "code_information": [
        {
          "code": "3039902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 676.2176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 531.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-VASCULAR/THIN     TR45W",
      "code_information": [
        {
          "code": "3039909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 239.6791,
          "maximum": 882.4512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 750.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM              XR30B",
      "code_information": [
        {
          "code": "3039911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 431,
          "minimum": 147.3438,
          "maximum": 676.2176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.8602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STANDARD BLUE     6R45B",
      "code_information": [
        {
          "code": "3039912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 415.7077,
          "maximum": 944.8139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 750.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40B",
      "code_information": [
        {
          "code": "3039913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1699,
          "minimum": 277.4939,
          "maximum": 1232.9643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1048.0197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD- STAPLE TCR-55",
      "code_information": [
        {
          "code": "3039914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 499,
          "minimum": 170.5906,
          "maximum": 456.002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 307.8057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-LINEAR CUTTER    TCR-75",
      "code_information": [
        {
          "code": "3039916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 820,
          "minimum": 280.3292,
          "maximum": 944.8139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 505.8129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40G",
      "code_information": [
        {
          "code": "3039917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1699,
          "minimum": 580.8284,
          "maximum": 1232.9643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1048.0197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER    TCT75",
      "code_information": [
        {
          "code": "3039918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1465,
          "minimum": 285.8354,
          "maximum": 1063.1505,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 903.6779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO GIA 30/3.5  030452",
      "code_information": [
        {
          "code": "3039932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2061,
          "minimum": 704.5835,
          "maximum": 1495.6677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1271.3175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-CARIOTOMY        205",
      "code_information": [
        {
          "code": "3039975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 465,
          "minimum": 158.9672,
          "maximum": 6833.3568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 286.8329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-DISP FILTRA 04259",
      "code_information": [
        {
          "code": "3039981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 7440.618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 360.8543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-OMMAYA    NL850-121x",
      "code_information": [
        {
          "code": "3040439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3043,
          "minimum": 170.1666,
          "maximum": 2208.3051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1877.0593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND          C8404",
      "code_information": [
        {
          "code": "3040501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 281.6966,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 508.2803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEXOR TENDON",
      "code_information": [
        {
          "code": "3040509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 600.588,
          "maximum": 1943.4246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1651.9109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-LONESTAR        3304",
      "code_information": [
        {
          "code": "3040511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1080,
          "minimum": 369.214,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 666.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ORTHO ALEXIS   HR004",
      "code_information": [
        {
          "code": "3040513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1611,
          "minimum": 310.3038,
          "maximum": 1169.1027,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 993.7373,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE        013593",
      "code_information": [
        {
          "code": "3040518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 190.7606,
          "maximum": 761.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.1995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-SURGICAL RING   3715",
      "code_information": [
        {
          "code": "3040521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1370,
          "minimum": 415.4067,
          "maximum": 994.209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-LOOPED 3 PRONG  5030",
      "code_information": [
        {
          "code": "3040525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 460.7832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND LG       C8303",
      "code_information": [
        {
          "code": "3040527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND MEDIUM   C8302",
      "code_information": [
        {
          "code": "3040530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XL       C8304",
      "code_information": [
        {
          "code": "3040532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 239.123,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 508.2803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND SMALL    C8301",
      "code_information": [
        {
          "code": "3040533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XSMALL   C8312",
      "code_information": [
        {
          "code": "3040534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-MALYUGIN ALL SZS MAL-000x",
      "code_information": [
        {
          "code": "3040661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1565,
          "minimum": 535.0185,
          "maximum": 2728.2266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.8 CANN DRI",
      "code_information": [
        {
          "code": "3040704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 1301.8301,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1056.0386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-2.0X7          AR-7200S",
      "code_information": [
        {
          "code": "3044850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 827,
          "minimum": 282.7222,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.1308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 2.3 BIPOLAR",
      "code_information": [
        {
          "code": "3044897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2785,
          "minimum": 952.0936,
          "maximum": 2021.0745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.9133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS MALLEABLE BI",
      "code_information": [
        {
          "code": "3044899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3215,
          "minimum": 336.9966,
          "maximum": 2333.1255,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1983.1567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION ANSPACH 111613",
      "code_information": [
        {
          "code": "3044922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 966,
          "minimum": 255.806,
          "maximum": 701.0262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 595.8723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68HP ALL",
      "code_information": [
        {
          "code": "3049715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRI PORT III PAL 303LS",
      "code_information": [
        {
          "code": "3050004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 580.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 4.0X170 144170",
      "code_information": [
        {
          "code": "3050009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 582.9185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CELLEBRITY CYTOLOGY",
      "code_information": [
        {
          "code": "3050015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 234,
          "minimum": 79.9964,
          "maximum": 4265.287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 144.3417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATIR SM DISP 13MM",
      "code_information": [
        {
          "code": "3055843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 833.5939,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.5185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 2ML 1506078",
      "code_information": [
        {
          "code": "3055845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1499,
          "minimum": 512.4554,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 924.6507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL ALL SZS 456.30Xs",
      "code_information": [
        {
          "code": "3055898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3677,
          "minimum": 1233.9859,
          "maximum": 2668.3989,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2268.1391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MISTY NEB W/FILTER",
      "code_information": [
        {
          "code": "3058511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 607.2612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-HELIOCOIDAL RASP 3.2MM",
      "code_information": [
        {
          "code": "3058512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1092,
          "minimum": 373.3164,
          "maximum": 995.9751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.5947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONE MILL DISP",
      "code_information": [
        {
          "code": "3058513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1791,
          "minimum": 262.4792,
          "maximum": 1299.7287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1104.7694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-CORE IRRIGATION",
      "code_information": [
        {
          "code": "3058514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 472,
          "minimum": 161.3602,
          "maximum": 605.5929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 291.1508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 2.3MM",
      "code_information": [
        {
          "code": "3058515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1089,
          "minimum": 372.2908,
          "maximum": 790.2873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 671.7442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-SOFT TOUCH RND FLUTED ALL",
      "code_information": [
        {
          "code": "3058516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND ALL SIZES",
      "code_information": [
        {
          "code": "3058517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 436.5614,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 787.7111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND COURSE ALL",
      "code_information": [
        {
          "code": "3058518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 3.0MM",
      "code_information": [
        {
          "code": "3058521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1089,
          "minimum": 372.2908,
          "maximum": 790.2873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 671.7442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CUTTING DIAMOND 25.4X0.8",
      "code_information": [
        {
          "code": "3058522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1042,
          "minimum": 356.2232,
          "maximum": 862.5111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 642.7525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 310.23S",
      "code_information": [
        {
          "code": "3058526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1551,
          "minimum": 530.2324,
          "maximum": 1125.5607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 956.7266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 02.7 CSS-072-27",
      "code_information": [
        {
          "code": "3058530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1347,
          "minimum": 460.492,
          "maximum": 977.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 830.8902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110 143110",
      "code_information": [
        {
          "code": "3058543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 683,
          "minimum": 233.4937,
          "maximum": 495.6531,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 421.3051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EPIDURAL 117\\\" INF 1633902",
      "code_information": [
        {
          "code": "3058611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 689.0079,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE 10X5",
      "code_information": [
        {
          "code": "3058612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1239,
          "minimum": 423.5706,
          "maximum": 1157.2441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 764.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-FLOW 50 COBLATION",
      "code_information": [
        {
          "code": "3058620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1833,
          "minimum": 626.6383,
          "maximum": 1330.2081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1130.6769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ACCOMINIZER 4.0",
      "code_information": [
        {
          "code": "3058623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 531.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 272.6455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STONCUTTER 5.5 7205331",
      "code_information": [
        {
          "code": "3058624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 956,
          "minimum": 279.1622,
          "maximum": 693.7692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 589.7038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3058625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4.0 1864G",
      "code_information": [
        {
          "code": "3058639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 14474.7269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL FLEX MED 27MM",
      "code_information": [
        {
          "code": "3058643",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 523.2901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.1436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-RETRIEVAL 30MM DGN-538-5",
      "code_information": [
        {
          "code": "3058644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 941,
          "minimum": 321.6948,
          "maximum": 682.8837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 580.4511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 2.0MM 5820-010-020",
      "code_information": [
        {
          "code": "3058655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1105,
          "minimum": 377.7607,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 681.6137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARTHREX ANGEL BMC",
      "code_information": [
        {
          "code": "3058674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDO FEEDING 12FR X 60”",
      "code_information": [
        {
          "code": "3058693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 233.1674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MINI 4.0 283459",
      "code_information": [
        {
          "code": "3058696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1275,
          "minimum": 435.8777,
          "maximum": 925.2675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 786.4774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 FULL RADIUS",
      "code_information": [
        {
          "code": "3058697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1275,
          "minimum": 435.8777,
          "maximum": 925.2675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 786.4774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 018 14MMX34CM",
      "code_information": [
        {
          "code": "3058707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 877.5258,
          "maximum": 3070.4367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2609.8712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-240",
      "code_information": [
        {
          "code": "3058716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1082,
          "minimum": 369.8978,
          "maximum": 785.2074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 667.4263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANOSCOPE-BEVELED DISP 103X18M",
      "code_information": [
        {
          "code": "3058720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 16442.2087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-EXPEL NEPHR I/E 8.3/22",
      "code_information": [
        {
          "code": "3058729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1262,
          "minimum": 431.4335,
          "maximum": 915.8334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 778.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH 15FR 71C",
      "code_information": [
        {
          "code": "3058737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 7838.7856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-VPAD 2 INS-0050",
      "code_information": [
        {
          "code": "3058749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2207,
          "minimum": 754.4957,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1361.3769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-ALWAYS ON TIP INS-0352",
      "code_information": [
        {
          "code": "3058751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1799.9537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-19 GA ANSO INS-0382",
      "code_information": [
        {
          "code": "3058752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1799.9537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GA ANSO INS 0392",
      "code_information": [
        {
          "code": "3058753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1799.9537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GA NITINOL INS-5410",
      "code_information": [
        {
          "code": "3058754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4175,
          "minimum": 1227.3127,
          "maximum": 3029.7975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2575.3279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 8MMX24CM",
      "code_information": [
        {
          "code": "3058757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 6MMX17CM",
      "code_information": [
        {
          "code": "3058758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 8523.9008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE DISTRACTOR DISP",
      "code_information": [
        {
          "code": "3058766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 192.8118,
          "maximum": 935.3602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.9006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 4MMX7CM",
      "code_information": [
        {
          "code": "3058776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MM X xCM",
      "code_information": [
        {
          "code": "3058777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 32205.4193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 AR 8943-16",
      "code_information": [
        {
          "code": "3058786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1013,
          "minimum": 346.3091,
          "maximum": 2388.4495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 624.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPIN EWC BIOPSY GUIDE",
      "code_information": [
        {
          "code": "3058788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3127,
          "minimum": 1069.0114,
          "maximum": 3022.4035,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1928.8743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DISP SHOULDER 1.8MM",
      "code_information": [
        {
          "code": "3058805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1659,
          "minimum": 567.1538,
          "maximum": 1455.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1023.3459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENTRAINER-AIR RT008",
      "code_information": [
        {
          "code": "3058809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.7687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 5.0 5050",
      "code_information": [
        {
          "code": "3058819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58043,
          "minimum": 19842.8621,
          "maximum": 42121.8051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35803.5343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 7.0 7050",
      "code_information": [
        {
          "code": "3058820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60044,
          "minimum": 99.5419,
          "maximum": 43573.9308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37037.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 BV-1 M8709",
      "code_information": [
        {
          "code": "3058836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 460.7832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 6MM X xxCM",
      "code_information": [
        {
          "code": "3058840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 2MMXxxCM",
      "code_information": [
        {
          "code": "3058843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4220,
          "minimum": 1442.6697,
          "maximum": 3062.454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2603.0859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX20CM",
      "code_information": [
        {
          "code": "3058844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5064,
          "minimum": 1731.2037,
          "maximum": 3674.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3123.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX30CM",
      "code_information": [
        {
          "code": "3058845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5591,
          "minimum": 1911.3664,
          "maximum": 4057.3887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3448.7804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 CX ALL",
      "code_information": [
        {
          "code": "3058847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HEATED AIRVO 900PT501",
      "code_information": [
        {
          "code": "3058860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 181.8447,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO SM OPT942",
      "code_information": [
        {
          "code": "3058861",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.7083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO MED OPT944",
      "code_information": [
        {
          "code": "3058862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.7083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO LARGE OPT946",
      "code_information": [
        {
          "code": "3058863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 86.1955,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.7083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-013-000 SZ4",
      "code_information": [
        {
          "code": "3058864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HEALING W/PLUG 30MM 95084",
      "code_information": [
        {
          "code": "3058868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 42.8197,
          "maximum": 156.7512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.2385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.5MM",
      "code_information": [
        {
          "code": "3058875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CONTOUR CERVICAL 13-15",
      "code_information": [
        {
          "code": "3058876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 61.7271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-RIB UNIVERSAL 8” MALE",
      "code_information": [
        {
          "code": "3058877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.2587,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3.0 1893G",
      "code_information": [
        {
          "code": "3058878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 66.1759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MMX15CM",
      "code_information": [
        {
          "code": "3058884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 129.5713,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SLIM MED",
      "code_information": [
        {
          "code": "3058885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 79.6545,
          "maximum": 216.3229,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 143.7249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-SYSTEM UA2007",
      "code_information": [
        {
          "code": "3058887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 162,
          "minimum": 55.3821,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 99.9289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WATER SUCTION BIOPSY VALVE",
      "code_information": [
        {
          "code": "3058903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.1898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-ACCUSTAT 125NM S 801015",
      "code_information": [
        {
          "code": "3058929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5081,
          "minimum": 280.8305,
          "maximum": 3687.2817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3134.1894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MIDLINE 5FR BIO FLO",
      "code_information": [
        {
          "code": "3058932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 1.4X27MM",
      "code_information": [
        {
          "code": "3058955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3358,
          "minimum": 1147.9822,
          "maximum": 12836.4563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2071.3655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON,CAPIOX HPH-1000",
      "code_information": [
        {
          "code": "3058981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 291.2689,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 525.5519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOBLADE GASTRO",
      "code_information": [
        {
          "code": "3058983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5049,
          "minimum": 522.734,
          "maximum": 3664.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3114.4504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORTHOLOCK 3X110MM EX",
      "code_information": [
        {
          "code": "3058990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 319.6436,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 576.7501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X 343MM",
      "code_information": [
        {
          "code": "3058991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1159,
          "minimum": 396.2214,
          "maximum": 841.0863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 714.9234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y935H",
      "code_information": [
        {
          "code": "3059006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.0X40X91MM",
      "code_information": [
        {
          "code": "3059015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 639.0514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-GENESYS HTA M006580211",
      "code_information": [
        {
          "code": "3059026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6769,
          "minimum": 870.8526,
          "maximum": 4912.2633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4175.4238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-CLEANING STICK 900PT602",
      "code_information": [
        {
          "code": "3059061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 93.4248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-QUADFUSE 9” EXT SMALLBORE",
      "code_information": [
        {
          "code": "3059062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 1661.0707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED OPT316",
      "code_information": [
        {
          "code": "3059066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 522,
          "minimum": 178.4535,
          "maximum": 401.5042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 321.9931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-HEADREST SOFTOUCH",
      "code_information": [
        {
          "code": "3059127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 12074.0432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ESOPHYX TIF R2007",
      "code_information": [
        {
          "code": "3059129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21712,
          "minimum": 1866.2716,
          "maximum": 15756.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13392.9386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTER CONNECT PT-5558-F",
      "code_information": [
        {
          "code": "3059131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 722.93,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.4128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 3.5X195 700353",
      "code_information": [
        {
          "code": "3059137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1228,
          "minimum": 419.81,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 757.4857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACQUIRE EUS FND",
      "code_information": [
        {
          "code": "3059156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 497.7095,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1635.2561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 2.0MM BIT",
      "code_information": [
        {
          "code": "3059170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2114,
          "minimum": 279.1622,
          "maximum": 1534.1298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1304.0103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-IMPLANT SIZING SG - x",
      "code_information": [
        {
          "code": "3059171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 6595.346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIALYZER-HIGH FLUX 1.6 720DH16",
      "code_information": [
        {
          "code": "3059177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 859.1745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ULTRAPERC FULL 100/573/000",
      "code_information": [
        {
          "code": "3059178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1545,
          "minimum": 30.5855,
          "maximum": 1121.2065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 953.0255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT MED",
      "code_information": [
        {
          "code": "3059179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 2180.4681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.9265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENVEO PRO LOADING",
      "code_information": [
        {
          "code": "3059185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2618,
          "minimum": 255.806,
          "maximum": 1899.8826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1614.9002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 1.5MM NEEDLES",
      "code_information": [
        {
          "code": "3059187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 460,
          "minimum": 157.2578,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 283.7487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-VERTEX DRILL 2.4MM",
      "code_information": [
        {
          "code": "3059197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 18503.6714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN 5X5CM FUD021",
      "code_information": [
        {
          "code": "3059209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-KNOTLESS S-TAK STEP 3MM",
      "code_information": [
        {
          "code": "3059213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 676.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW OSC SAGITTAL xxMM",
      "code_information": [
        {
          "code": "3059220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 8367.0806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 384.9113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO DURACLIP 235CM 11MM",
      "code_information": [
        {
          "code": "3059232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 16632.951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 869.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT LG",
      "code_information": [
        {
          "code": "3059245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 39.9135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.9265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT SM",
      "code_information": [
        {
          "code": "3059246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 2632.0213,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.9265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-POLAR COMBO 1232PP",
      "code_information": [
        {
          "code": "3059252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 907,
          "minimum": 310.0714,
          "maximum": 780.2083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 559.4784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-TRI STAPLE 2.0 SIG30AVM",
      "code_information": [
        {
          "code": "3059259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2871,
          "minimum": 981.494,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1770.962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND 1.0MM",
      "code_information": [
        {
          "code": "3059273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 151.2592,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 787.7111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION MED",
      "code_information": [
        {
          "code": "3059281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 279,
          "minimum": 95.3803,
          "maximum": 4504.9661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 172.0998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 15\\\" ADJ ILIO",
      "code_information": [
        {
          "code": "3059288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 328,
          "minimum": 112.1317,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.3252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP ALL",
      "code_information": [
        {
          "code": "3059603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 2352.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT 111645",
      "code_information": [
        {
          "code": "3059922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 266.3127,
          "maximum": 664.5395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 480.5223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X140 143140",
      "code_information": [
        {
          "code": "3059924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1195,
          "minimum": 408.5285,
          "maximum": 2945.1056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 737.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ABC SINGLE FUNCTION",
      "code_information": [
        {
          "code": "3059973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 850,
          "minimum": 290.5851,
          "maximum": 726.2666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 524.3183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATCHER-STONE WITH TUB 840-750",
      "code_information": [
        {
          "code": "3059984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 825,
          "minimum": 282.0385,
          "maximum": 4179.6476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 508.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP       7-382",
      "code_information": [
        {
          "code": "3059989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 6650.3999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ISOLATOR  BIP   OSL2",
      "code_information": [
        {
          "code": "3059996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11959,
          "minimum": 627.8369,
          "maximum": 8678.6463,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7376.8494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-LINEAR 60GRN      TX60G",
      "code_information": [
        {
          "code": "3060001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 913,
          "minimum": 305.855,
          "maximum": 662.5641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.1795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM GREEN        XR60G",
      "code_information": [
        {
          "code": "3060002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 550,
          "minimum": 84.5272,
          "maximum": 399.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 339.2647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE   RC014MIBB",
      "code_information": [
        {
          "code": "3060082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 68.9564,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 576.7501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CORONARY PERFUSN 10004",
      "code_information": [
        {
          "code": "3060083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 477.1338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.4888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEX IRIS     611.75",
      "code_information": [
        {
          "code": "3060129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 858,
          "minimum": 175.1715,
          "maximum": 622.6506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 529.253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 8\\\"  7708-000-10",
      "code_information": [
        {
          "code": "3060132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 228.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.3062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VESSEL           30003",
      "code_information": [
        {
          "code": "3060134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 101,
          "minimum": 34.5284,
          "maximum": 1063.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-T-TUBE 16FR       0099830",
      "code_information": [
        {
          "code": "3060199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 825.2524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE MEDIUM   9893",
      "code_information": [
        {
          "code": "3060289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 170.2487,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 307.1888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-UNIV     60-6010-001",
      "code_information": [
        {
          "code": "3060315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 68.9564,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 333.0963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERZ-REFLECTIVE PK   PM 8005",
      "code_information": [
        {
          "code": "3060317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 143.4738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.4888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-SPRING CLIP 6MM  CSOFT6",
      "code_information": [
        {
          "code": "3060318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-SILVERSTEIN PK 1428010",
      "code_information": [
        {
          "code": "3060385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 71.4498,
          "maximum": 12457.1961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.9206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0 CT-2 Z332H",
      "code_information": [
        {
          "code": "3060417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.9751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROGRAMMER-TEST STIM 3531",
      "code_information": [
        {
          "code": "3060442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2604,
          "minimum": 259.1426,
          "maximum": 1889.7228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1606.2644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MINI HOOK 357501",
      "code_information": [
        {
          "code": "3060443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 414.2945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 287.4498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 4.0MM 03.000.012S",
      "code_information": [
        {
          "code": "3060451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 745,
          "minimum": 254.6893,
          "maximum": 540.6465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 459.5495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 5.0MM 03.000.015S",
      "code_information": [
        {
          "code": "3060452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 333.0963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90X9.5 05.003.126S",
      "code_information": [
        {
          "code": "3060455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 1953.0232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 384.9113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 10M",
      "code_information": [
        {
          "code": "3060460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3512,
          "minimum": 398.1676,
          "maximum": 2548.6584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2166.3596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT",
      "code_information": [
        {
          "code": "3060472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 5MM PAL-508LL",
      "code_information": [
        {
          "code": "3060475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 1614.9144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 456.4653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-FAST FIX 360 KPSC",
      "code_information": [
        {
          "code": "3060478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1344,
          "minimum": 459.4664,
          "maximum": 975.3408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 829.0397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU RIGHT 7210424",
      "code_information": [
        {
          "code": "3060485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1334,
          "minimum": 456.0477,
          "maximum": 968.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 822.8712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU LEFT 7210423",
      "code_information": [
        {
          "code": "3060486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 798.8143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STRT 7210426",
      "code_information": [
        {
          "code": "3060488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 798.8143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.3MM CROSSPIN 62-23333",
      "code_information": [
        {
          "code": "3060489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STR 7210425",
      "code_information": [
        {
          "code": "3060494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 909.3021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 772.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SILICONE 8CM        205108",
      "code_information": [
        {
          "code": "3061090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1750,
          "minimum": 598.2635,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1079.4787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-SINGLE HOLE 1877-01-010",
      "code_information": [
        {
          "code": "3062492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2040,
          "minimum": 95.6492,
          "maximum": 1480.428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1258.3638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-3' EPV100 VENT",
      "code_information": [
        {
          "code": "3068320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.0973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX PEDS MAXP",
      "code_information": [
        {
          "code": "3068323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 283.0549,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP VIBRATORY ACAPELLA",
      "code_information": [
        {
          "code": "3068325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 509,
          "minimum": 31.6977,
          "maximum": 369.3813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 313.9741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED W/7' TUBING",
      "code_information": [
        {
          "code": "3068327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 199.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BIPAP PERFORMATRAK LARGE",
      "code_information": [
        {
          "code": "3068330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 35.5904,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT DUAL LIMB",
      "code_information": [
        {
          "code": "3068331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT CAPNOXYGEN C02-01",
      "code_information": [
        {
          "code": "3068332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 102.3224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT/PED 8’ 58051",
      "code_information": [
        {
          "code": "3068333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.4995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-MYOSURE            40-902",
      "code_information": [
        {
          "code": "3078533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 171,
          "minimum": 58.4589,
          "maximum": 3316.5804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.4805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-DURA           20-xxxx",
      "code_information": [
        {
          "code": "3078541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5964,
          "minimum": 398.1676,
          "maximum": 4328.0748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3678.8636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-DURAL           1314",
      "code_information": [
        {
          "code": "3078593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 868.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH INDWELLING SLIT 295-6",
      "code_information": [
        {
          "code": "3078730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 1133.5434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 963.5119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-KARLEN BALLOON    CS-01700",
      "code_information": [
        {
          "code": "3078823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 207.4253,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML 0797208",
      "code_information": [
        {
          "code": "3078850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 276.3817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 137.5564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU, DIALYSIS 2.5% 2L 5B9876",
      "code_information": [
        {
          "code": "3078852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 497,
          "minimum": 28.3611,
          "maximum": 360.6729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 306.572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML  07138-09",
      "code_information": [
        {
          "code": "3078858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 51,
          "minimum": 17.4351,
          "maximum": 865.8477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 31.4591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK E3773-45C",
      "code_information": [
        {
          "code": "3078982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1254,
          "minimum": 428.6985,
          "maximum": 1022.6679,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 773.5236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MAS TLIF LIGHT   3400033",
      "code_information": [
        {
          "code": "3079040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 636.1784,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1759.8588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MULTILEAD TRIAL     3013",
      "code_information": [
        {
          "code": "3079055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1144,
          "minimum": 391.0934,
          "maximum": 830.2008,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 705.6707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.0X13        AR-8400EX",
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        {
          "code": "3079215",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 330.1935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.6645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.-X13 AR-8500EX",
      "code_information": [
        {
          "code": "3079228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 280.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER        20400161S/10",
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        {
          "code": "3079240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 99.5419,
          "maximum": 222.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 188.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL G2 TIP 35CM",
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        {
          "code": "3079250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 364.8016,
          "maximum": 2415.8553,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2053.477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 ABRADER    72201518",
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        {
          "code": "3079252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 656,
          "minimum": 224.2633,
          "maximum": 476.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 404.6503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR    72201513",
      "code_information": [
        {
          "code": "3079253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 637,
          "minimum": 217.7679,
          "maximum": 462.2709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 392.9303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3079254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 598,
          "minimum": 204.4352,
          "maximum": 433.9686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5 FULL RADIUS 7205305",
      "code_information": [
        {
          "code": "3079257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 498.2656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.6645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 FULL RADIUM 7205306",
      "code_information": [
        {
          "code": "3079261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 272.6455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 INCISOR     7205345",
      "code_information": [
        {
          "code": "3079262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 1761.1687,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 272.6455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL 45CM    NSLG2C45A",
      "code_information": [
        {
          "code": "3079282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3167,
          "minimum": 1082.686,
          "maximum": 2298.2919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1953.5481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 36\\\"   HAR36",
      "code_information": [
        {
          "code": "3079285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3146,
          "minimum": 1075.5068,
          "maximum": 2283.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1940.5944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HS FOCUS 9CM CRVD  HAR9F",
      "code_information": [
        {
          "code": "3079290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2871,
          "minimum": 680.1103,
          "maximum": 2083.4847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1770.962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INPUT 8FR PS    080011",
      "code_information": [
        {
          "code": "3079468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 425.9726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.1329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNLER SM-LG    9009-s",
      "code_information": [
        {
          "code": "3079475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 766,
          "minimum": 261.8685,
          "maximum": 555.8862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 472.5033,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-RENAL 20CM      900-123",
      "code_information": [
        {
          "code": "3079482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 313.5024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 266.477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-EXT BILATERAL DYNJP8004A",
      "code_information": [
        {
          "code": "3079499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 2033.1016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-CORNEAL DISP      E5699",
      "code_information": [
        {
          "code": "3079626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.0024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-CAROTID ALL     2000-00s",
      "code_information": [
        {
          "code": "3079680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 6136.0074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909504",
      "code_information": [
        {
          "code": "3079703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11962,
          "minimum": 2091.4921,
          "maximum": 8680.8234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7378.6999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5070",
      "code_information": [
        {
          "code": "3079707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3761,
          "minimum": 1285.7537,
          "maximum": 2729.3577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2319.954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5071",
      "code_information": [
        {
          "code": "3079709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3761,
          "minimum": 1285.7537,
          "maximum": 11631.3876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2319.954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PHACO .9MM  8065-750517",
      "code_information": [
        {
          "code": "3079736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 429,
          "minimum": 146.66,
          "maximum": 7567.9649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 264.6265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SMALL VIT PLUS 1",
      "code_information": [
        {
          "code": "3079745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1675,
          "minimum": 572.6236,
          "maximum": 7567.9649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1033.2154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STAR            AR-1606",
      "code_information": [
        {
          "code": "3079766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 877,
          "minimum": 299.8155,
          "maximum": 636.4389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 540.9731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 12MM        CB12LT",
      "code_information": [
        {
          "code": "3079770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1106,
          "minimum": 378.1025,
          "maximum": 8681.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.2306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM KII          CFS22",
      "code_information": [
        {
          "code": "3079789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.0701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-FIBER          AR-7209SN",
      "code_information": [
        {
          "code": "3079790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 80.0784,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 676.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM KII           CFS02",
      "code_information": [
        {
          "code": "3079791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 114.5566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM THREADED KII CTS22",
      "code_information": [
        {
          "code": "3079792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.0701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM THREADED KII  CTS0S",
      "code_information": [
        {
          "code": "3079793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 165.1617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.2931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATABLE OVAL",
      "code_information": [
        {
          "code": "3079795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 297,
          "minimum": 101.5339,
          "maximum": 8681.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SILICONE         400561",
      "code_information": [
        {
          "code": "3079975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 550,
          "minimum": 188.0257,
          "maximum": 399.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 339.2647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER MINI        1500",
      "code_information": [
        {
          "code": "3079992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 425.9859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 362.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER SMALL       1500",
      "code_information": [
        {
          "code": "3079994",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 554,
          "minimum": 189.3931,
          "maximum": 402.0378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 341.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER PETITE      1500",
      "code_information": [
        {
          "code": "3079996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 8572.8376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 362.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-AGGRESSIVE 3.5   283315",
      "code_information": [
        {
          "code": "3080062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 353.4522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ULTRA AGGRESSIVE 283325",
      "code_information": [
        {
          "code": "3080067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 1213.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 353.4522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.5MM AR-1204AS-95",
      "code_information": [
        {
          "code": "3080073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2182,
          "minimum": 745.9491,
          "maximum": 1583.4774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1345.9558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 10MM AR-1204AS-100",
      "code_information": [
        {
          "code": "3080074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1582.7517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1345.3389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.0MM AR1204AS90",
      "code_information": [
        {
          "code": "3080075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1819,
          "minimum": 207.4253,
          "maximum": 1320.0483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1122.0411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-OPTIMOLD NASAL   PS1688",
      "code_information": [
        {
          "code": "3080204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 195.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3080355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 352,
          "minimum": 113.4444,
          "maximum": 255.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 217.1294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-EGIA 60 MED   EGIA60AVM",
      "code_information": [
        {
          "code": "3080925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 477.6899,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 966.5961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-ENDOCLIP MULTI    ER320",
      "code_information": [
        {
          "code": "3080932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 859,
          "minimum": 293.6619,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 529.8699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR VASCULAR  TX30V",
      "code_information": [
        {
          "code": "3081085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 81.7467,
          "maximum": 697.3977,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 592.788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT 12”",
      "code_information": [
        {
          "code": "3081101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.6762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT RIGHT",
      "code_information": [
        {
          "code": "3081102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.6762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY RT ANGLE Y PORT 12”",
      "code_information": [
        {
          "code": "3081103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 117.8932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.6762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIEDER TS101DC",
      "code_information": [
        {
          "code": "3081129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 594,
          "minimum": 203.0677,
          "maximum": 5771.7619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 366.4059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-POLYSORB 55      SZ 200",
      "code_information": [
        {
          "code": "3081173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4940,
          "minimum": 497.1534,
          "maximum": 3584.958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3047.2143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN INSORB 2030",
      "code_information": [
        {
          "code": "3081400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 894,
          "minimum": 305.6272,
          "maximum": 4780.7917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 551.4594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZS ECS's",
      "code_information": [
        {
          "code": "3081408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1763,
          "minimum": 602.7077,
          "maximum": 4780.7917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1087.4977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZ CDHxxA",
      "code_information": [
        {
          "code": "3081415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1570,
          "minimum": 536.7278,
          "maximum": 1451.9771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 968.4466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWER  PLEE60A",
      "code_information": [
        {
          "code": "3081416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2611,
          "minimum": 892.6091,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1610.5823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-INTERNAL EEA   EEAXL25",
      "code_information": [
        {
          "code": "3081425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1376.3475,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWERED PCE60A",
      "code_information": [
        {
          "code": "3081432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2475,
          "minimum": 846.1155,
          "maximum": 1796.1075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1526.6914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 45       EC45A",
      "code_information": [
        {
          "code": "3081433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2038,
          "minimum": 696.7206,
          "maximum": 1478.9766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1257.1301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 60       EC60A",
      "code_information": [
        {
          "code": "3081436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2635,
          "minimum": 900.8139,
          "maximum": 1912.2195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1625.3866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-EGIA HANDLE  EGIAUSTND",
      "code_information": [
        {
          "code": "3081443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2985,
          "minimum": 1020.4666,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1841.2823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDO GIA UNIVER 030449",
      "code_information": [
        {
          "code": "3081491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 464.8996,
          "maximum": 1915.848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1628.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-THICK TISSUE      TRT75",
      "code_information": [
        {
          "code": "3081494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3752.0067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.6824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3081502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 61.171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT STR 35WD",
      "code_information": [
        {
          "code": "3081503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAYS-SURGICAL PACK    3311-8G",
      "code_information": [
        {
          "code": "3081506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER   TLC-75",
      "code_information": [
        {
          "code": "3081530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 60BL      TX60B",
      "code_information": [
        {
          "code": "3081535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 904,
          "minimum": 309.0458,
          "maximum": 1678.8659,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR  40B     CS40B",
      "code_information": [
        {
          "code": "3081542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3019,
          "minimum": 1032.09,
          "maximum": 2190.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40G      CS40G",
      "code_information": [
        {
          "code": "3081544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3019,
          "minimum": 1032.09,
          "maximum": 2190.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDOPATH VASC PVE35A",
      "code_information": [
        {
          "code": "3081550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2231,
          "minimum": 762.7005,
          "maximum": 1619.0367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1376.1812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-HEAVY WIRE 90    TLH90",
      "code_information": [
        {
          "code": "3081554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 791,
          "minimum": 270.4151,
          "maximum": 574.0287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 487.9244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3081569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 12302.6003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.1329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A28-2",
      "code_information": [
        {
          "code": "3082047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21603,
          "minimum": 7385.3066,
          "maximum": 15677.2971,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13325.7025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A25-25",
      "code_information": [
        {
          "code": "3082066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21603,
          "minimum": 7385.3066,
          "maximum": 15677.2971,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13325.7025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-AAA MAIN    ETCF3636C49E",
      "code_information": [
        {
          "code": "3082068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 20042,
          "minimum": 6851.6555,
          "maximum": 14544.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 12362.8075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STICK-FIBER            AR-7209",
      "code_information": [
        {
          "code": "3082089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 27356.7834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKINETTE-BARRIER   NON22535",
      "code_information": [
        {
          "code": "3082135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 366.4699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE FOOT        014407",
      "code_information": [
        {
          "code": "3082217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 659,
          "minimum": 225.2889,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 406.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRAIGHT           1123",
      "code_information": [
        {
          "code": "3082330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 198.8418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.0155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUMP-PERICARDIAL 1/4 CONNECTOR",
      "code_information": [
        {
          "code": "3082395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 164.6056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.6489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURG-STRIP 1/2X6       80-1451",
      "code_information": [
        {
          "code": "3082416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 296,
          "minimum": 101.192,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 182.5861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPRALOOP-BRUCKER/MESSROGHLI",
      "code_information": [
        {
          "code": "3082421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1727,
          "minimum": 498.2656,
          "maximum": 1253.2839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.2913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-NUKNITT 3X4      1943",
      "code_information": [
        {
          "code": "3082430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.6931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC-0       173024",
      "code_information": [
        {
          "code": "3082450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 625.5534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 531.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC 2-0 173023",
      "code_information": [
        {
          "code": "3082453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 207.4253,
          "maximum": 625.5534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 531.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 698G",
      "code_information": [
        {
          "code": "3082542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 235.2303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-GORETEX CV-3      3N06A",
      "code_information": [
        {
          "code": "3082544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 423,
          "minimum": 144.6088,
          "maximum": 306.9711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.9254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J947H",
      "code_information": [
        {
          "code": "3082558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 4065.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONO PDSII        Z740D",
      "code_information": [
        {
          "code": "3082562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 305,
          "minimum": 104.2688,
          "maximum": 221.3385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 188.1377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ALIANCE        5060-05",
      "code_information": [
        {
          "code": "3082566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 1441.4112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-FLOSEAL 10ML   1503352",
      "code_information": [
        {
          "code": "3082592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2592,
          "minimum": 886.1137,
          "maximum": 5547.0975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1598.8622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING NEMA   3730ANS",
      "code_information": [
        {
          "code": "3082996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2435.9209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ACCESSORY           502",
      "code_information": [
        {
          "code": "3083003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4011,
          "minimum": 1371.22,
          "maximum": 2910.7827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2474.1653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BIOGLUE 5ML  BG3515-5US",
      "code_information": [
        {
          "code": "3083007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5122,
          "minimum": 760.7448,
          "maximum": 3717.0354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3159.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANS CATH 10\\\" PM040-A",
      "code_information": [
        {
          "code": "3083014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1368,
          "minimum": 467.6711,
          "maximum": 992.7576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 843.844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-CYSTO 25X5/8  581610",
      "code_information": [
        {
          "code": "3083019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 50,
          "minimum": 17.0932,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 30.8422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE VNUS        CFP",
      "code_information": [
        {
          "code": "3083021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION CATH  PM010-A",
      "code_information": [
        {
          "code": "3083022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 435,
          "minimum": 148.7112,
          "maximum": 333.1039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION 5\\\"    PM020-A",
      "code_information": [
        {
          "code": "3083023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 369.4902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-COLLECTION   003984-901",
      "code_information": [
        {
          "code": "3083083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 69.7404,
          "maximum": 867.516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.8364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-STERIDRAPE 8 7/8   1075",
      "code_information": [
        {
          "code": "3083104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 832.4817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URETERAL DIAL   240-100",
      "code_information": [
        {
          "code": "3083141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1497,
          "minimum": 511.7717,
          "maximum": 1086.3729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 923.417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-PROTACK DEVICE 5MM",
      "code_information": [
        {
          "code": "3083191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3464,
          "minimum": 331.4356,
          "maximum": 2513.8248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2136.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB AR-13226",
      "code_information": [
        {
          "code": "3083200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 596,
          "minimum": 203.7515,
          "maximum": 575.5635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 367.6396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-BONE SCREW 3.5X50  311.349",
      "code_information": [
        {
          "code": "3083203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 1343.5376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.35 2883-02-043",
      "code_information": [
        {
          "code": "3083212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 522.734,
          "maximum": 1753.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1490.2975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-IQ DISPOSABLE 72-1010",
      "code_information": [
        {
          "code": "3083214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 310.8599,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 579.8343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-TVT DEVICE .5\\\"X18\\\" 810041",
      "code_information": [
        {
          "code": "3083229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5520.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-          AR-7237-7T",
      "code_information": [
        {
          "code": "3083486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 520,
          "minimum": 177.7697,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 320.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS2",
      "code_information": [
        {
          "code": "3083597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 134.5762,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-BIOGLUE FAN        BGST-12",
      "code_information": [
        {
          "code": "3083615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 82.7313,
          "maximum": 593.3587,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.2765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE ALL    UMx67x's",
      "code_information": [
        {
          "code": "3083622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1067,
          "minimum": 207.4253,
          "maximum": 774.3219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 658.1736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 35CM     3908",
      "code_information": [
        {
          "code": "3083637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 287.4498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CURVED DISP I&A 8065751512",
      "code_information": [
        {
          "code": "3083715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE POLYMER I/A",
      "code_information": [
        {
          "code": "3083720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 222,
          "minimum": 75.894,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 136.9396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-TURBOSONICS     8065750853",
      "code_information": [
        {
          "code": "3083760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 50.6051,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 460.7832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EMBLEM TUNNELING 4711",
      "code_information": [
        {
          "code": "3084601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5623.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-LUKI MUCOUS SPEC  8646-04",
      "code_information": [
        {
          "code": "3084800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 6",
      "code_information": [
        {
          "code": "3084821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 321.353,
          "maximum": 726.2666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 579.8343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA70",
      "code_information": [
        {
          "code": "3084824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.5996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA80",
      "code_information": [
        {
          "code": "3084827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1345,
          "minimum": 100.098,
          "maximum": 976.0665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 829.6565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/METER ALL P4PxxSD",
      "code_information": [
        {
          "code": "3084870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 130.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.0321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CHG PREP        DYND70663",
      "code_information": [
        {
          "code": "3084874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 65.313,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BETADINE PREP   DYND70672",
      "code_information": [
        {
          "code": "3084876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 3099.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1    4609764",
      "code_information": [
        {
          "code": "3084884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 111.7578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAPS-FINGER DISP PACK 9900s",
      "code_information": [
        {
          "code": "3084885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 190,
          "minimum": 64.9543,
          "maximum": 12260.3367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.2005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-LAP CB EXPLOR    G26908",
      "code_information": [
        {
          "code": "3084925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3560,
          "minimum": 443.2117,
          "maximum": 2583.492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2195.9682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SOLU IRRISEPT .5% CHG",
      "code_information": [
        {
          "code": "3084928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 797,
          "minimum": 272.4663,
          "maximum": 3137.5162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 491.6255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP 26-23-0757",
      "code_information": [
        {
          "code": "3084992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 7593.5455,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.9503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFF74",
      "code_information": [
        {
          "code": "3085110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 503.8266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-100LP",
      "code_information": [
        {
          "code": "3085111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 906,
          "minimum": 174.6154,
          "maximum": 657.4842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 558.8616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED     CTF73",
      "code_information": [
        {
          "code": "3085112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 523.2901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-100L",
      "code_information": [
        {
          "code": "3085113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 941,
          "minimum": 141.2494,
          "maximum": 682.8837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 580.4511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREATED      CTF03",
      "code_information": [
        {
          "code": "3085117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.6786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-8MM KII OPTICAL   COQ19",
      "code_information": [
        {
          "code": "3085120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR47",
      "code_information": [
        {
          "code": "3085135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR85",
      "code_information": [
        {
          "code": "3085137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 315.3087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM KII OPTICAL  COR37",
      "code_information": [
        {
          "code": "3085140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 567,
          "minimum": 193.8374,
          "maximum": 411.4719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM LONG         C0R39",
      "code_information": [
        {
          "code": "3085142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 567,
          "minimum": 149.5909,
          "maximum": 411.4719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM KII FIOS      CFFxx",
      "code_information": [
        {
          "code": "3085145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM LONG BLADED CFB71",
      "code_information": [
        {
          "code": "3085160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 490.4802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-THORACOPOR 11.5  179303",
      "code_information": [
        {
          "code": "3085163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 882,
          "minimum": 178.5081,
          "maximum": 640.0674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 544.0573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM THREADED     CTF33",
      "code_information": [
        {
          "code": "3085165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 1116.0927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-SPLIT           82-4095",
      "code_information": [
        {
          "code": "3085170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2007,
          "minimum": 268.0402,
          "maximum": 1456.4799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1238.0079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL BLADELESS     B8LT",
      "code_information": [
        {
          "code": "3085202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 482,
          "minimum": 164.7789,
          "maximum": 760.1887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.3193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP LONG VS101505",
      "code_information": [
        {
          "code": "3085203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1367,
          "minimum": 467.3293,
          "maximum": 992.0319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 843.2271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 5MM           B5LT",
      "code_information": [
        {
          "code": "3085207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1543,
          "minimum": 390.3822,
          "maximum": 1119.7551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 951.7918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BIO PREP BONE PREP",
      "code_information": [
        {
          "code": "3085533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1349,
          "minimum": 100.6541,
          "maximum": 978.9693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 832.1239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 8.0FR MEGA IAB",
      "code_information": [
        {
          "code": "3085537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1496,
          "minimum": 511.4298,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 922.8001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ARMSTRONG TEFLON DRAIN",
      "code_information": [
        {
          "code": "3085540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 137.5564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-TIBIAL 111651",
      "code_information": [
        {
          "code": "3085541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 757.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 262.776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PROCEDURE TRACKING 107130",
      "code_information": [
        {
          "code": "3085542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 225.2205,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 840.1429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE 111320",
      "code_information": [
        {
          "code": "3085543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 405,
          "minimum": 138.4553,
          "maximum": 454.3337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 249.8222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX IMPACTION",
      "code_information": [
        {
          "code": "3085544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 817,
          "minimum": 279.3036,
          "maximum": 592.8969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 503.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144140",
      "code_information": [
        {
          "code": "3085545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 685.7865,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 582.9185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON ULTRASIL",
      "code_information": [
        {
          "code": "3085560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-ENDO EXCEL 15MM   B15LT",
      "code_information": [
        {
          "code": "3085620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1548,
          "minimum": 529.2068,
          "maximum": 1123.3836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 954.8761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR ARMSTRONG    10-56121",
      "code_information": [
        {
          "code": "3085635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 155.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 132.0048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR PAPARELLA 1.14MM",
      "code_information": [
        {
          "code": "3085636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 881.4185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 132.0048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACHEAL EMG  8229307",
      "code_information": [
        {
          "code": "3085638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1585,
          "minimum": 88.976,
          "maximum": 1150.2345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 977.6993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH ALL SZS 822970x",
      "code_information": [
        {
          "code": "3085644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2759,
          "minimum": 207.9814,
          "maximum": 2002.2063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1701.8754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 20FR   0100-20",
      "code_information": [
        {
          "code": "3085648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 491.0363,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-KAMVAC            5300-00",
      "code_information": [
        {
          "code": "3085723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 301.8667,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 544.6741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MOSS GASTROSTOMY  5-17719",
      "code_information": [
        {
          "code": "3085779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 375.9236,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1138.6959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T MODIFIED        24-0072",
      "code_information": [
        {
          "code": "3085882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 230.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.1567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COLLECTION DISP BKT-506",
      "code_information": [
        {
          "code": "3086006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 83.415,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.2872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OXYFLEX        SA008000",
      "code_information": [
        {
          "code": "3086095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX INFLOW  AQL-110",
      "code_information": [
        {
          "code": "3086102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      80-9102",
      "code_information": [
        {
          "code": "3086103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 715,
          "minimum": 99.5419,
          "maximum": 518.8755,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.0442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      5120-10",
      "code_information": [
        {
          "code": "3086105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 535.5243,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.2575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AIRSEAL ASM-EVAC",
      "code_information": [
        {
          "code": "3086106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 963,
          "minimum": 301.4062,
          "maximum": 698.8491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 594.0217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATOR STR  18-95522",
      "code_information": [
        {
          "code": "3086107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 542,
          "minimum": 43.3758,
          "maximum": 393.3294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.33,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LASER VACUUM    VT10424",
      "code_information": [
        {
          "code": "3086109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 93.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.1139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LIPOSUCTION   DYND50112",
      "code_information": [
        {
          "code": "3086110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 425.4165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MAIN PUMP       AR-6410",
      "code_information": [
        {
          "code": "3086111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 99.5419,
          "maximum": 555.1605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 471.8864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/4\\\"X1/16\\\"X8'      3108",
      "code_information": [
        {
          "code": "3086139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 132,
          "minimum": 45.1262,
          "maximum": 279.1622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 81.4235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OUTFLOW         AR-6430",
      "code_information": [
        {
          "code": "3086141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO      284508",
      "code_information": [
        {
          "code": "3086142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 450,
          "minimum": 153.8392,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 277.5802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO IRRIG OUT",
      "code_information": [
        {
          "code": "3086144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 109.5517,
          "maximum": 441.9513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 375.6586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-ASPIRATION AT-10003-6",
      "code_information": [
        {
          "code": "3086181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 349.7869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.5185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TISSEEL         0600065",
      "code_information": [
        {
          "code": "3086182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 629,
          "minimum": 112.8883,
          "maximum": 456.4653,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 387.9955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TRANSDUCER 48 61000",
      "code_information": [
        {
          "code": "3086185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 165.7178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.2195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARTHREX-TIB CANN      AR-1802D",
      "code_information": [
        {
          "code": "3086190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 456.5581,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.8198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-& TIP-SMALL   9009-18",
      "code_information": [
        {
          "code": "3086203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 821,
          "minimum": 280.6711,
          "maximum": 595.7997,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 506.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER & TIP-LARGE   9009-16",
      "code_information": [
        {
          "code": "3086205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 724,
          "minimum": 247.5102,
          "maximum": 1804.5445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 446.5958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-STIMULATOR LEAD   402",
      "code_information": [
        {
          "code": "3086210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3245,
          "minimum": 207.4253,
          "maximum": 2354.8965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2001.662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE SUPPORT 79-82160",
      "code_information": [
        {
          "code": "3086407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 504.9388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 70x-xxxx ALL SIZES",
      "code_information": [
        {
          "code": "3086409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 341.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.3359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH 2-0   170057",
      "code_information": [
        {
          "code": "3086965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 813,
          "minimum": 277.9361,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 501.495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VAC-SUPER TURBO     ASC4250-01",
      "code_information": [
        {
          "code": "3087110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 58.9466,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP CVD ALL 21500s",
      "code_information": [
        {
          "code": "3087119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CURVED 7MM     21853",
      "code_information": [
        {
          "code": "3087130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 72.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 8MM CVD   20317",
      "code_information": [
        {
          "code": "3087132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 2133.1996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.4318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VOICE-PROLARYN        8044M0K5",
      "code_information": [
        {
          "code": "3087140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3836,
          "minimum": 1311.3936,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2366.2174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVULATOME-LEMAITRE   1009-00",
      "code_information": [
        {
          "code": "3087919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 13534,
          "minimum": 870.8526,
          "maximum": 9821.6238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8348.3802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8916-14",
      "code_information": [
        {
          "code": "3087939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 812,
          "minimum": 277.5943,
          "maximum": 589.2684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 500.8781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 UNDYED    VLOCM1904",
      "code_information": [
        {
          "code": "3088955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 7.7854,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 333.7131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J761D",
      "code_information": [
        {
          "code": "3088965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 309.7477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.2658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VIOLET    VLOCM0804",
      "code_information": [
        {
          "code": "3088967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 557,
          "minimum": 58.9466,
          "maximum": 404.2149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 343.5827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0    MCP496G",
      "code_information": [
        {
          "code": "3088972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 7.7854,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J441",
      "code_information": [
        {
          "code": "3088976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 34.4782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7.4021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS2     1666G",
      "code_information": [
        {
          "code": "3088979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J218H",
      "code_information": [
        {
          "code": "3088985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 8.7084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7.4021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y495G",
      "code_information": [
        {
          "code": "3088991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 444.3239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.0024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       D5526",
      "code_information": [
        {
          "code": "3088992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 799,
          "minimum": 35.5904,
          "maximum": 579.8343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 492.8592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 6-0           Z432H",
      "code_information": [
        {
          "code": "3088993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 7.7854,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0  ALL  833-000s",
      "code_information": [
        {
          "code": "3088998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 533,
          "minimum": 7.7854,
          "maximum": 386.7981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 328.7784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J727D",
      "code_information": [
        {
          "code": "3089002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 7.7854,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J905T",
      "code_information": [
        {
          "code": "3089005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 97.3175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J739D",
      "code_information": [
        {
          "code": "3089007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 7.7854,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J906G",
      "code_information": [
        {
          "code": "3089013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 107.4036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.2931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J740D",
      "code_information": [
        {
          "code": "3089014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 7.7854,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J775D",
      "code_information": [
        {
          "code": "3089024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.1626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J789D",
      "code_information": [
        {
          "code": "3089025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 45.6002,
          "maximum": 156.7512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.2385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z881G",
      "code_information": [
        {
          "code": "3089026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 124.5664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8806H",
      "code_information": [
        {
          "code": "3089027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 53.3856,
          "maximum": 162.5568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z990G",
      "code_information": [
        {
          "code": "3089030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 7.7854,
          "maximum": 69.6672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J834G",
      "code_information": [
        {
          "code": "3089039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J833G",
      "code_information": [
        {
          "code": "3089042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8824G",
      "code_information": [
        {
          "code": "3089048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 7.7854,
          "maximum": 42.8163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y493G",
      "code_information": [
        {
          "code": "3089059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y490G",
      "code_information": [
        {
          "code": "3089060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 7.7854,
          "maximum": 72.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8521H",
      "code_information": [
        {
          "code": "3089064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8581H",
      "code_information": [
        {
          "code": "3089065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 75.4728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.1519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8557H",
      "code_information": [
        {
          "code": "3089066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8833H",
      "code_information": [
        {
          "code": "3089069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8623H",
      "code_information": [
        {
          "code": "3089072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 55.0539,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8522H",
      "code_information": [
        {
          "code": "3089073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8534H",
      "code_information": [
        {
          "code": "3089074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J904T",
      "code_information": [
        {
          "code": "3089079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 7.7854,
          "maximum": 84.9069,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      PX82H",
      "code_information": [
        {
          "code": "3089097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8523H",
      "code_information": [
        {
          "code": "3089100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 112.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8706H",
      "code_information": [
        {
          "code": "3089103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.2195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8805H",
      "code_information": [
        {
          "code": "3089105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 161.8311,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 137.5564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8709H",
      "code_information": [
        {
          "code": "3089106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 266,
          "minimum": 90.9361,
          "maximum": 193.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 164.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8720H",
      "code_information": [
        {
          "code": "3089110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 50.6051,
          "maximum": 142.2372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.9016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8556H",
      "code_information": [
        {
          "code": "3089113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 66.0387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.1329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8710H",
      "code_information": [
        {
          "code": "3089114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 133.464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.8992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8304H",
      "code_information": [
        {
          "code": "3089117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 240,
          "minimum": 82.0476,
          "maximum": 174.168,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 148.0428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8703H",
      "code_information": [
        {
          "code": "3089121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 251,
          "minimum": 85.8081,
          "maximum": 182.1507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 154.8281,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J213H",
      "code_information": [
        {
          "code": "3089123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 7.7854,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO       AR-4068-xxx",
      "code_information": [
        {
          "code": "3089131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 33.9221,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         G124H",
      "code_information": [
        {
          "code": "3089132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         U256H",
      "code_information": [
        {
          "code": "3089133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 2-0       G123H",
      "code_information": [
        {
          "code": "3089145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 148.4787,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       1792G",
      "code_information": [
        {
          "code": "3089146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 193.7619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 164.6976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "3089147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 248,
          "minimum": 7.7854,
          "maximum": 179.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 152.9776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 0       L104G",
      "code_information": [
        {
          "code": "3089150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 61.7271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.0949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       G172H",
      "code_information": [
        {
          "code": "3089154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 33.9221,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U203",
      "code_information": [
        {
          "code": "3089156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1637G",
      "code_information": [
        {
          "code": "3089157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 69.6672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0     1916G",
      "code_information": [
        {
          "code": "3089161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     1824H",
      "code_information": [
        {
          "code": "3089172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A304H",
      "code_information": [
        {
          "code": "3089177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 7.7854,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 5-0          K890H",
      "code_information": [
        {
          "code": "3089195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 7.7854,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           709H",
      "code_information": [
        {
          "code": "3089202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 118,
          "minimum": 40.3401,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.7877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0  X524H",
      "code_information": [
        {
          "code": "3089204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 7.7854,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5        B449T",
      "code_information": [
        {
          "code": "3089212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 4-0      X204H",
      "code_information": [
        {
          "code": "3089217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.2361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 3-0      X936H",
      "code_information": [
        {
          "code": "3089226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 93.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5-0      X727H",
      "code_information": [
        {
          "code": "3089227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 7.7854,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        690G",
      "code_information": [
        {
          "code": "3089238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       1666H",
      "code_information": [
        {
          "code": "3089239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1663H",
      "code_information": [
        {
          "code": "3089244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 7.7854,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z340H",
      "code_information": [
        {
          "code": "3089254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 7.7854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.1684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 0         L880G",
      "code_information": [
        {
          "code": "3089258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 7.7854,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.0949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      SXP82",
      "code_information": [
        {
          "code": "3089266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 607,
          "minimum": 207.512,
          "maximum": 440.4999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 374.4249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND2-0       SXP86",
      "code_information": [
        {
          "code": "3089267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 666,
          "minimum": 7.7854,
          "maximum": 483.3162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 410.8188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X927H",
      "code_information": [
        {
          "code": "3089281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z879G",
      "code_information": [
        {
          "code": "3089283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0 Z494G",
      "code_information": [
        {
          "code": "3089284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y497G",
      "code_information": [
        {
          "code": "3089286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 66.0387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.1329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0        687G",
      "code_information": [
        {
          "code": "3089287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.9834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X513H",
      "code_information": [
        {
          "code": "3089288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2 MX69G",
      "code_information": [
        {
          "code": "3089290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 73.8428,
          "maximum": 215.2107,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.2385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS O EZ10G",
      "code_information": [
        {
          "code": "3089291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 280.8459,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 238.719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          EJ10G",
      "code_information": [
        {
          "code": "3089292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 345.8942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 238.719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       M8720",
      "code_information": [
        {
          "code": "3089293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 622,
          "minimum": 212.6399,
          "maximum": 451.3854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 383.6776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       M8303",
      "code_information": [
        {
          "code": "3089294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 778,
          "minimum": 7.7854,
          "maximum": 564.5946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 479.9054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       U202H",
      "code_information": [
        {
          "code": "3089307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U213H",
      "code_information": [
        {
          "code": "3089308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 49.4929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8843H",
      "code_information": [
        {
          "code": "3089314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 100.6541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.8992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J555G",
      "code_information": [
        {
          "code": "3089316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.6489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            C027D",
      "code_information": [
        {
          "code": "3089318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX45D",
      "code_information": [
        {
          "code": "3089320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 207,
          "minimum": 70.766,
          "maximum": 150.2199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.6869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 8-0         2815G",
      "code_information": [
        {
          "code": "3089323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 35.0343,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.2195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X523H",
      "code_information": [
        {
          "code": "3089324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X977H",
      "code_information": [
        {
          "code": "3089325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 5-0     1915G",
      "code_information": [
        {
          "code": "3089326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 167.9422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.0024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0           Z774D",
      "code_information": [
        {
          "code": "3089328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 7.7854,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.2872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 10-0      9003G",
      "code_information": [
        {
          "code": "3089335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 7.7854,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.7629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        793G",
      "code_information": [
        {
          "code": "3089348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 192,
          "minimum": 37.8148,
          "maximum": 139.3344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 118.4342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 699G",
      "code_information": [
        {
          "code": "3089354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON/MONO    ETH562H",
      "code_information": [
        {
          "code": "3089357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 CT1  J-945-H",
      "code_information": [
        {
          "code": "3089362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 33.366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.1684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0        585H",
      "code_information": [
        {
          "code": "3089363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C0125",
      "code_information": [
        {
          "code": "3089364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 179.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMD2B413",
      "code_information": [
        {
          "code": "3089371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 322,
          "minimum": 110.0805,
          "maximum": 233.6754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPD2B408",
      "code_information": [
        {
          "code": "3089372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 34.4782,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 211.5778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       U204H",
      "code_information": [
        {
          "code": "3089379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J428H",
      "code_information": [
        {
          "code": "3089381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 46,
          "minimum": 15.7258,
          "maximum": 38.3709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 28.3749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6/0 P-1    J489G",
      "code_information": [
        {
          "code": "3089382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 7-0        J488G",
      "code_information": [
        {
          "code": "3089384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPP1A400",
      "code_information": [
        {
          "code": "3089386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 370,
          "minimum": 99.5419,
          "maximum": 268.509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 228.2326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2.0 ALL PX83Hs",
      "code_information": [
        {
          "code": "3089390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1654G",
      "code_information": [
        {
          "code": "3089394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 7.7854,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NUROLON 4-0       C584D",
      "code_information": [
        {
          "code": "3089396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 236,
          "minimum": 80.6801,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 145.5754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPD2B413",
      "code_information": [
        {
          "code": "3089403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 391,
          "minimum": 48.9368,
          "maximum": 283.7487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.1864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z493G",
      "code_information": [
        {
          "code": "3089407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN 4-0 1644G",
      "code_information": [
        {
          "code": "3089408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE RS23",
      "code_information": [
        {
          "code": "3089410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 378.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC PBT xxMM",
      "code_information": [
        {
          "code": "3089416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 1362.445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 420.0714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1B406",
      "code_information": [
        {
          "code": "3089420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 380,
          "minimum": 129.9086,
          "maximum": 275.766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 234.4011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MONOPTY 16GX20CM",
      "code_information": [
        {
          "code": "3089701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 1121.6537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE EICA8875-01",
      "code_information": [
        {
          "code": "3090040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2017,
          "minimum": 689.5414,
          "maximum": 1463.7369,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1244.1764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-TURBINATE RED EICA4845-01",
      "code_information": [
        {
          "code": "3090049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2053,
          "minimum": 701.8486,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1266.3828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,TOPAZ MICRO ACH4041-0",
      "code_information": [
        {
          "code": "3090061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1656.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .045      WS-1106ST",
      "code_information": [
        {
          "code": "3090191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER #2          AR-7200",
      "code_information": [
        {
          "code": "3091195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER 2-0         AR-7220",
      "code_information": [
        {
          "code": "3091196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5         310.243",
      "code_information": [
        {
          "code": "3091211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 291.2689,
          "maximum": 618.2964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 525.5519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6MM AGK16150",
      "code_information": [
        {
          "code": "3091237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 287.4498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-2.5MM DRILL XFO082501",
      "code_information": [
        {
          "code": "3091238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 966.5961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE          1806-0080S",
      "code_information": [
        {
          "code": "3091250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1197,
          "minimum": 207.4253,
          "maximum": 868.6629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 738.3635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3091317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .054          WS-1406ST",
      "code_information": [
        {
          "code": "3091319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K              0152-0218S",
      "code_information": [
        {
          "code": "3091346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 881,
          "minimum": 99.5419,
          "maximum": 639.3417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 543.4404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 040-365",
      "code_information": [
        {
          "code": "3091419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1510,
          "minimum": 198.5277,
          "maximum": 1095.807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 931.4359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 046-072",
      "code_information": [
        {
          "code": "3091422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 357,
          "minimum": 122.0458,
          "maximum": 259.0749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.2137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY    047-032",
      "code_information": [
        {
          "code": "3091425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 295,
          "minimum": 100.8501,
          "maximum": 342.5576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 181.9693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE TIP      03.211.410",
      "code_information": [
        {
          "code": "3091436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 616,
          "minimum": 157.3763,
          "maximum": 447.0312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.9765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 5.0 310.63",
      "code_information": [
        {
          "code": "3091500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3340,
          "minimum": 55.61,
          "maximum": 2423.838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2060.2623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 21665",
      "code_information": [
        {
          "code": "3091501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-PROGEL PGPS002",
      "code_information": [
        {
          "code": "3091508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 494.929,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION SEID",
      "code_information": [
        {
          "code": "3091510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 890,
          "minimum": 304.2597,
          "maximum": 645.873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 548.992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND M 2.5MM 03.000.007S",
      "code_information": [
        {
          "code": "3091511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 105.659,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 488.5412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/2X3/32 /10 3610",
      "code_information": [
        {
          "code": "3091513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 190,
          "minimum": 64.9543,
          "maximum": 645.076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.2005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLUE-GUN CMS REVOLUTION",
      "code_information": [
        {
          "code": "3091516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1029,
          "minimum": 351.7789,
          "maximum": 1269.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 634.7335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT 5MM EB210",
      "code_information": [
        {
          "code": "3091517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 1656.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1407.6403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT FINE EB230",
      "code_information": [
        {
          "code": "3091518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2953,
          "minimum": 313.6404,
          "maximum": 2142.9921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1821.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE CANNU FLEX .042X12",
      "code_information": [
        {
          "code": "3091560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 121.2298,
          "maximum": 409.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.9006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TEMPORARY CARDIA  024-100",
      "code_information": [
        {
          "code": "3091561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 158.2026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 134.4722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8MM FIBULA ROD 80-0642",
      "code_information": [
        {
          "code": "3091572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.5996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-FACIAL DENTAL 714-6IN-GEL",
      "code_information": [
        {
          "code": "3093187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 249,
          "minimum": 85.1244,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 153.5944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ACCESSORY       3550-02",
      "code_information": [
        {
          "code": "3093195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 207.4253,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 579.8343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOBUTTON-CL ULTRA PAC 1.2",
      "code_information": [
        {
          "code": "3094000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2461,
          "minimum": 841.3294,
          "maximum": 1785.9477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1518.0555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACCESSORY-TIP COVER     400180",
      "code_information": [
        {
          "code": "3100010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SNAPFIT 15 DEG    400152",
      "code_information": [
        {
          "code": "3102750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCL0316",
      "code_information": [
        {
          "code": "3115410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 184.9489,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 333.7131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCM1545",
      "code_information": [
        {
          "code": "3115420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 184.9489,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 333.7131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA ARM        420279",
      "code_information": [
        {
          "code": "3115515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA HEAD       420273",
      "code_information": [
        {
          "code": "3115525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM    420015",
      "code_information": [
        {
          "code": "3115580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM XI 470015",
      "code_information": [
        {
          "code": "3115585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 652,
          "minimum": 156.8202,
          "maximum": 473.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 402.1829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM LONG XI   470358",
      "code_information": [
        {
          "code": "3155025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 272.8632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.9337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM XI        470357",
      "code_information": [
        {
          "code": "3155030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 272.8632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.9337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 5MM        400161",
      "code_information": [
        {
          "code": "3170005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.6786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 8.5-13MM   420206",
      "code_information": [
        {
          "code": "3170007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 124.5664,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA            400077",
      "code_information": [
        {
          "code": "3170010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA ENDOWRIST XI",
      "code_information": [
        {
          "code": "3170020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-8MM XI 570361",
      "code_information": [
        {
          "code": "3170050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.9503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL s.I.e.    410322",
      "code_information": [
        {
          "code": "3170060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 1147.6403,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.7487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL XI        480322",
      "code_information": [
        {
          "code": "3170070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 170.1666,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.7487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUB. & FILTER 20400162S/10",
      "code_information": [
        {
          "code": "3171250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 306,
          "minimum": 104.6106,
          "maximum": 222.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 188.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-ENDOWRIST STAPLER 45",
      "code_information": [
        {
          "code": "3171320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 6652.0682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909506",
      "code_information": [
        {
          "code": "3171350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11962,
          "minimum": 976.5116,
          "maximum": 8680.8234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7378.6999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 12M OMS-T12BT",
      "code_information": [
        {
          "code": "3175750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1756,
          "minimum": 600.3147,
          "maximum": 1274.3292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1083.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-SINGLE SITE 8.5    428065",
      "code_information": [
        {
          "code": "3185345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1488,
          "minimum": 508.6949,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 917.8654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEXIBLE         3100A",
      "code_information": [
        {
          "code": "3240013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1449,
          "minimum": 201.3082,
          "maximum": 1051.5393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 893.8084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GENERATOR INFANT LP FLOW",
      "code_information": [
        {
          "code": "3240072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 596,
          "minimum": 203.7515,
          "maximum": 432.5172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 367.6396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INFANT O2 DELIVERY   RT329",
      "code_information": [
        {
          "code": "3240073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 476,
          "minimum": 62.2832,
          "maximum": 345.4332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 293.6182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RESUS S/USE       900RD010",
      "code_information": [
        {
          "code": "3240075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 433.758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG HYDROGEL",
      "code_information": [
        {
          "code": "3240083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODES-EEG LOW IMPEDENCE",
      "code_information": [
        {
          "code": "3240085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 72.8491,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTERFACE-TRACHEOSTOMY HI FLOW",
      "code_information": [
        {
          "code": "3240105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 273.0451,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.7083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BELLOWS & WATER TRAP 3100A",
      "code_information": [
        {
          "code": "3240167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 177.3959,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.6931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CONNECTING TUBING.   3100",
      "code_information": [
        {
          "code": "3240170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 319,
          "minimum": 109.0549,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.7736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 6 FR    196",
      "code_information": [
        {
          "code": "3249995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.35,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 8 FR    198",
      "code_information": [
        {
          "code": "3249997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.35,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE MAC 5FR    1925",
      "code_information": [
        {
          "code": "3249998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 138.6087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.8174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE 14FR 12\\\" 220135",
      "code_information": [
        {
          "code": "3250000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT UNCUFFED",
      "code_information": [
        {
          "code": "3281990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 47.8246,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.6931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3282370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.0487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XS      006950",
      "code_information": [
        {
          "code": "3283013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 196.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.4995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP THERAPY  \\\"ACAPELLA\\\"",
      "code_information": [
        {
          "code": "3283015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 111.22,
          "maximum": 256.8978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 218.3631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION  LG     006965",
      "code_information": [
        {
          "code": "3283017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XLG     006970",
      "code_information": [
        {
          "code": "3283018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUVETTE-CO2 DISP ADULT MP01062",
      "code_information": [
        {
          "code": "3284354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 198,
          "minimum": 53.9417,
          "maximum": 143.6886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 122.1353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER 5MM",
      "code_information": [
        {
          "code": "3290045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 176.8398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.0487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL MED HIGH FLOW",
      "code_information": [
        {
          "code": "3290046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 230.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.1567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL SM HIGH FLOW",
      "code_information": [
        {
          "code": "3290047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL LG HIGH FLOW",
      "code_information": [
        {
          "code": "3290048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP           23-0757",
      "code_information": [
        {
          "code": "3290060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 91.2004,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.5209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT L599-130",
      "code_information": [
        {
          "code": "3290061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 205.757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.1626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT W/MR290 SINGLE",
      "code_information": [
        {
          "code": "3290062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 370,
          "minimum": 126.49,
          "maximum": 268.509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 228.2326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BREATHING NEONATAL",
      "code_information": [
        {
          "code": "3290074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-INFANT DUAL FLOW RT26",
      "code_information": [
        {
          "code": "3290077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 82.3028,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 272.6455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOWMETER-PEAK          002068",
      "code_information": [
        {
          "code": "3290080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 107.4036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.2931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-CPAP NASAL NSC-001",
      "code_information": [
        {
          "code": "3290082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOW-CONT CYSTO GREENLYT",
      "code_information": [
        {
          "code": "3290084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 102.3224,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP MED",
      "code_information": [
        {
          "code": "3290127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 133.5288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.4995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP SMALL",
      "code_information": [
        {
          "code": "3290128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 133.5288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.4995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOSE-AIR MODEL 205 DISP",
      "code_information": [
        {
          "code": "3290145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 174.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED SM NIV",
      "code_information": [
        {
          "code": "3290170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.0725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED MED NIV",
      "code_information": [
        {
          "code": "3290171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.0725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED LG NIV",
      "code_information": [
        {
          "code": "3290172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 56.7222,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.0725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 42MM    RD804-10",
      "code_information": [
        {
          "code": "3290178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP AIRLIFE W/FILTER",
      "code_information": [
        {
          "code": "3290184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 171.8349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL XS INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 309,
          "minimum": 105.6362,
          "maximum": 224.2413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 190.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL LG INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL MED INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 206.8245,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.8008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 308,
          "minimum": 58.3905,
          "maximum": 223.5156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 189.9883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 60MM    RD806-10",
      "code_information": [
        {
          "code": "3290194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 76.1985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.7687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK,OXY ADULT OM-1125-8",
      "code_information": [
        {
          "code": "3290214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 149.0348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED SMALL NIV",
      "code_information": [
        {
          "code": "3290215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.3145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.2872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED LARGE NIV",
      "code_information": [
        {
          "code": "3290217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.3145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 78.9708,
          "maximum": 167.6367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 142.4912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED LG NIV",
      "code_information": [
        {
          "code": "3290219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 391.4944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 157.2955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP ALOHA ALO100",
      "code_information": [
        {
          "code": "3290220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 704,
          "minimum": 66.1759,
          "maximum": 510.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 434.2589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-MISTY FINITY  002534",
      "code_information": [
        {
          "code": "3290245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 119,
          "minimum": 40.6819,
          "maximum": 422.636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 73.4046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOPPER-DECANNULATION SZ4",
      "code_information": [
        {
          "code": "3290354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 760,
          "minimum": 194.635,
          "maximum": 551.532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 468.8022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DIRECTIONAL BALLARD  22059",
      "code_information": [
        {
          "code": "3290385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 388.7139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.6572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 5MM PROX",
      "code_information": [
        {
          "code": "3290400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 699,
          "minimum": 238.9635,
          "maximum": 507.2643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.1747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY SLT UNCUFF 5MM",
      "code_information": [
        {
          "code": "3290401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 679,
          "minimum": 232.1262,
          "maximum": 492.7503,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 418.8378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEST-SPU ALL SZS  WRAP-SLOTTED",
      "code_information": [
        {
          "code": "3290504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 819,
          "minimum": 279.9873,
          "maximum": 594.3483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 505.1961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING WHITE    PMV005",
      "code_information": [
        {
          "code": "3290506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 876,
          "minimum": 299.4736,
          "maximum": 635.7132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 540.3562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING PURPLE  PMV2001",
      "code_information": [
        {
          "code": "3290508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 875,
          "minimum": 33.366,
          "maximum": 634.9875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 539.7394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP LPEEP",
      "code_information": [
        {
          "code": "3290509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP ADJ          2K8082",
      "code_information": [
        {
          "code": "3290515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 265.2597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-THERAPRESSURE     262895",
      "code_information": [
        {
          "code": "3300010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 51,
          "minimum": 17.4351,
          "maximum": 582.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 31.4591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOFT GOODS FOR CPM UNIT",
      "code_information": [
        {
          "code": "3302945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 325.8746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA VARICEX S",
      "code_information": [
        {
          "code": "3310024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-ENDURA KIT         775410",
      "code_information": [
        {
          "code": "3310985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.1436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BGE   A840235",
      "code_information": [
        {
          "code": "3310986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 91.4382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BLACK  554617",
      "code_information": [
        {
          "code": "3310987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 53.6728,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.8447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX RED   A840241",
      "code_information": [
        {
          "code": "3310989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 89.9868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.4888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 6CMX5CM",
      "code_information": [
        {
          "code": "3310991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 8CMX5CM",
      "code_information": [
        {
          "code": "3310992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 10CMX5M",
      "code_information": [
        {
          "code": "3310993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDL K 12CMX5M",
      "code_information": [
        {
          "code": "3311000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 100.098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.2741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL 15CMX.4CMX2.5M",
      "code_information": [
        {
          "code": "3311010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 161.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.0321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ12 12CM",
      "code_information": [
        {
          "code": "3311075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 290,
          "minimum": 84.5272,
          "maximum": 210.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 178.8851,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ7 7CM",
      "code_information": [
        {
          "code": "3311076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL SOFT",
      "code_information": [
        {
          "code": "3311078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 126.2347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.0487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING C",
      "code_information": [
        {
          "code": "3311085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 164.7339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.0238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AID-\\\"CLEAN EASY\\\" GRIP REACH",
      "code_information": [
        {
          "code": "3311086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 203.196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 172.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING D",
      "code_information": [
        {
          "code": "3311094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 391.4944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 134.4722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3311107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 29.4733,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-LG HDL      C6298-01-25",
      "code_information": [
        {
          "code": "3311117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 53,
          "minimum": 18.1188,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.6928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3311123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.1612,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 6CMX5M",
      "code_information": [
        {
          "code": "3311138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 74.5174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 8CMX5M RL",
      "code_information": [
        {
          "code": "3311139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 44.488,
          "maximum": 97.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.6572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-IONTOPHOR IOGEL 2971",
      "code_information": [
        {
          "code": "3311144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 58.3905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYBRESIS PATCH",
      "code_information": [
        {
          "code": "3311150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 33.366,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALU 1.5X3.5 PK 2393",
      "code_information": [
        {
          "code": "3311153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 86.1955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ALUM LTX FREE ALL",
      "code_information": [
        {
          "code": "3311156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXERCISER-POWER GRIP HAND",
      "code_information": [
        {
          "code": "3311157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 63.5869,
          "maximum": 402.0603,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.7332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-COMFY HAND/THUMB",
      "code_information": [
        {
          "code": "3311158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 723,
          "minimum": 28.3611,
          "maximum": 524.6811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.9789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3311161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 37.2587,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUTRODE RND 1.25\\\"",
      "code_information": [
        {
          "code": "3311163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT OVAL PK 2\\\"X4\\\"",
      "code_information": [
        {
          "code": "3311164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.6465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-WEIGHTED EZ GRIP 920675",
      "code_information": [
        {
          "code": "3311165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 91.7565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELECTRODE ADULT       9050",
      "code_information": [
        {
          "code": "3311167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 141.8055,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.7794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3311174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 36.7026,
          "maximum": 185.0535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 157.2955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT SQ PK  1.5X3.5",
      "code_information": [
        {
          "code": "3311178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 293.0647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.7118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT M&LGE",
      "code_information": [
        {
          "code": "3311191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 48.3807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARD-FOOD INVISIBLE      1115",
      "code_information": [
        {
          "code": "3311192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 87.3077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-TRACTION EXER ALL C5032s",
      "code_information": [
        {
          "code": "3311193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 35.5904,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.8447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT S&XS",
      "code_information": [
        {
          "code": "3311194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 280.2744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LAVAGE    0210112000",
      "code_information": [
        {
          "code": "3311197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 504,
          "minimum": 172.2999,
          "maximum": 365.7528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 310.8899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPM SOFTGOOD FOR HOME UNIT",
      "code_information": [
        {
          "code": "3311235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 238.7553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3311250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 319,
          "minimum": 104.5468,
          "maximum": 231.4983,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.7736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HIP/KNEE W/26 REACHER",
      "code_information": [
        {
          "code": "3311251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH UPPER EXTREMITY",
      "code_information": [
        {
          "code": "3311255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 28.9172,
          "maximum": 134.9802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.7332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-ELASTO-GEL CAST/SPL  A8273",
      "code_information": [
        {
          "code": "3311340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 65.0637,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.0759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3311347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3311357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 87.8638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-D WRIST BRACE ALL SIZES",
      "code_information": [
        {
          "code": "3311363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.4615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADDING-FOAM \\\"KOMPREX\\\" SHEET",
      "code_information": [
        {
          "code": "3311369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPOON-WEIGHTED EZ GRIP 920688",
      "code_information": [
        {
          "code": "3311406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-LONG-32\\\"       A665009",
      "code_information": [
        {
          "code": "3311472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 28.9172,
          "maximum": 84.9069,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-ALUMINUM 32\\\"      4107",
      "code_information": [
        {
          "code": "3311475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 37.7364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.0759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-STANDARD 26\\\"    A80-42",
      "code_information": [
        {
          "code": "3311479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-SAMMONS PRESTON   4109",
      "code_information": [
        {
          "code": "3311480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINTING-EZEFORM 1/8”X18”X24”",
      "code_information": [
        {
          "code": "3311600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 475,
          "minimum": 92.3126,
          "maximum": 344.7075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 293.0014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELBOW NEOPRENE XL",
      "code_information": [
        {
          "code": "3311602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 166,
          "minimum": 56.7496,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.3963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-JOINT JACK MED   A52542",
      "code_information": [
        {
          "code": "3311613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 203.9217,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.3334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 6\\\"-7\\\"",
      "code_information": [
        {
          "code": "3311625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 211.5778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 3-14",
      "code_information": [
        {
          "code": "3311701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.6596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT S/M A812731",
      "code_information": [
        {
          "code": "3311702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND COMFY LG ADULT",
      "code_information": [
        {
          "code": "3311703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 444,
          "minimum": 151.788,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 273.8792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT/LARGE DYNAPRO",
      "code_information": [
        {
          "code": "3311704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 460.7832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-STABILIZER WALKER ROLYAN",
      "code_information": [
        {
          "code": "3311708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 463,
          "minimum": 158.2834,
          "maximum": 335.9991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 285.5992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WALKER HIGH OVATION LRG",
      "code_information": [
        {
          "code": "3311709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 549,
          "minimum": 23.3562,
          "maximum": 398.4093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 338.6479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-LMB FINGER HUGGER",
      "code_information": [
        {
          "code": "3312530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 83.7569,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 151.127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EZEFORM-ANTI MICROBIAL 564393",
      "code_information": [
        {
          "code": "3315521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 572,
          "minimum": 121.7859,
          "maximum": 415.1004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 352.8353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3397811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 349,
          "minimum": 47.2685,
          "maximum": 253.2693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PALM SHIELD RIGHT",
      "code_information": [
        {
          "code": "3397815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND RIGHT/MED A31228",
      "code_information": [
        {
          "code": "3397817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 226.4184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 192.4556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT MED A31227",
      "code_information": [
        {
          "code": "3397818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 78.9662,
          "maximum": 226.4184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 192.4556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-SKIN DERMABOND  DNX12",
      "code_information": [
        {
          "code": "3500034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 99.5419,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.8198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SOFTGOODS CPM        20533",
      "code_information": [
        {
          "code": "3500038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 46.1563,
          "maximum": 235.8525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 200.4746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "3500087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LMA DISP ALL SZ  1250xx",
      "code_information": [
        {
          "code": "3500245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 91.7565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 34FR  123034",
      "code_information": [
        {
          "code": "3500275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 38.3709,
          "maximum": 119.7405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.7794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 28F   123028",
      "code_information": [
        {
          "code": "3500280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 26FR  123026",
      "code_information": [
        {
          "code": "3500283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 30FR  123030",
      "code_information": [
        {
          "code": "3500285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 32FR  123032",
      "code_information": [
        {
          "code": "3500288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACMENT KNEE COLD L/XL",
      "code_information": [
        {
          "code": "3500410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 7.7854,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP   260815",
      "code_information": [
        {
          "code": "3500759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 127,
          "minimum": 43.4168,
          "maximum": 243.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.3393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED & 60MM AIRWAY",
      "code_information": [
        {
          "code": "3500786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT & 90MM AIRWY",
      "code_information": [
        {
          "code": "3500788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 38.927,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.1626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASPIRATOR-MECONIUM HCI   N0101",
      "code_information": [
        {
          "code": "3500789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 88.4199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-INFANT  5442160xx",
      "code_information": [
        {
          "code": "3500792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 42.8197,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-COLLECTION 4X8 BX     9778",
      "code_information": [
        {
          "code": "3500815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 55.8789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    C0135T",
      "code_information": [
        {
          "code": "3501012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 7.7854,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.8992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0        697H",
      "code_information": [
        {
          "code": "3501065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 57.3303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 FS-3  1665G",
      "code_information": [
        {
          "code": "3501070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 249.1328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXTERNAL CSF DRAIN INS8700",
      "code_information": [
        {
          "code": "3501130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 448,
          "minimum": 99.5419,
          "maximum": 325.1136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.3466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC VERALNK ULTLNK500",
      "code_information": [
        {
          "code": "3501755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 666,
          "minimum": 83.415,
          "maximum": 483.3162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 410.8188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18FR5CC 0119L18",
      "code_information": [
        {
          "code": "3501790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 31.6977,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC       6261",
      "code_information": [
        {
          "code": "3502002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 91.2004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EFFLUENT 5L PRISMAFLEX",
      "code_information": [
        {
          "code": "3502007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.1626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 20F30C  0167L20",
      "code_information": [
        {
          "code": "3502010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 205.2009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL   TCS1000",
      "code_information": [
        {
          "code": "3502048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 369,
          "minimum": 60.0588,
          "maximum": 267.7833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 227.6158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 400     7000LL",
      "code_information": [
        {
          "code": "3502063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 1283.4788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST MED RIGHT 5001-0",
      "code_information": [
        {
          "code": "3502580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 118.2891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.5457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LARGE RT  5001-04",
      "code_information": [
        {
          "code": "3502590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 704.0226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.5457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-LIFEBAND FOR AUTOPULSE",
      "code_information": [
        {
          "code": "3502593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1266,
          "minimum": 93.4248,
          "maximum": 918.7362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 780.9258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST X-LG LT 5001-10",
      "code_information": [
        {
          "code": "3502600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-FLEXMASTER 6\\\" 79-98718",
      "code_information": [
        {
          "code": "3502681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 304.1867,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.0131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF C",
      "code_information": [
        {
          "code": "3502706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 547,
          "minimum": 187.0001,
          "maximum": 396.9579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 337.4142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF D",
      "code_information": [
        {
          "code": "3502707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 475,
          "minimum": 162.3858,
          "maximum": 344.7075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 293.0014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-BUNNY W/FRAME & LINER",
      "code_information": [
        {
          "code": "3502709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 351,
          "minimum": 119.9946,
          "maximum": 254.7207,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 216.5126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-LEG FULL SM 9128-01",
      "code_information": [
        {
          "code": "3502720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 345,
          "minimum": 90.6443,
          "maximum": 250.3665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 212.8115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3502751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 47.2685,
          "maximum": 118.2891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.5457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMIN 46-62 13992000",
      "code_information": [
        {
          "code": "3503080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 377.5919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-HOOD ALL  0408-8xx-000",
      "code_information": [
        {
          "code": "3503348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 679,
          "minimum": 35.5904,
          "maximum": 492.7503,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 418.8378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ENV INFANT   8004-01",
      "code_information": [
        {
          "code": "3503370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 686.2274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT ARM",
      "code_information": [
        {
          "code": "3504148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT BOOT",
      "code_information": [
        {
          "code": "3504149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT FULL LENGTH",
      "code_information": [
        {
          "code": "3504150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 88.5354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED ARM",
      "code_information": [
        {
          "code": "3504151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED BOOT",
      "code_information": [
        {
          "code": "3504152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 12\\\" 13960000*",
      "code_information": [
        {
          "code": "3504230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.9834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER EYE        607120",
      "code_information": [
        {
          "code": "3504353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 96.7614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MAC 3&4",
      "code_information": [
        {
          "code": "3504355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 126.2718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MIL 2&3",
      "code_information": [
        {
          "code": "3504357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 126.2718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "3504552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 96.5181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1.5\\\" CT\\\"",
      "code_information": [
        {
          "code": "3504553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 181.2886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM      100 1974",
      "code_information": [
        {
          "code": "3504663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 326,
          "minimum": 45.0441,
          "maximum": 236.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.0915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM     12-7 1972",
      "code_information": [
        {
          "code": "3504665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CHANNELED         KVL03C",
      "code_information": [
        {
          "code": "3504905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST EZWALK XL 2001-05",
      "code_information": [
        {
          "code": "3505035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 35.5904,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST STAT ALL 2001-00s",
      "code_information": [
        {
          "code": "3505545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 55.0539,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA TENDERWRAP 4\\\"X10YDS",
      "code_information": [
        {
          "code": "3505570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 156.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WAFFLE  ALL SIZES    FW's",
      "code_information": [
        {
          "code": "3505575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.3334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2515H****",
      "code_information": [
        {
          "code": "3505815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 4263.0626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.1519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICAL MED",
      "code_information": [
        {
          "code": "3505906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 83.4555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE HEAVY LARGE",
      "code_information": [
        {
          "code": "3505907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 74.7471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE CHILD   3004-12",
      "code_information": [
        {
          "code": "3505955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 1675.5293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION ATEC",
      "code_information": [
        {
          "code": "3506118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3506181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.0487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-7FR \\\"SLIC\\\"       SC-14701",
      "code_information": [
        {
          "code": "3506470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.9751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CURITY ULTRAMER 6FR  6006",
      "code_information": [
        {
          "code": "3506758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 22G   383591",
      "code_information": [
        {
          "code": "3507108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 90.7125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 24G   383590",
      "code_information": [
        {
          "code": "3507111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 111.7761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW ARTERIAL VENOUS",
      "code_information": [
        {
          "code": "3507185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.9858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3W 16F 5CC  0119L16",
      "code_information": [
        {
          "code": "3507187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 101.598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 30CC ALL 123600As",
      "code_information": [
        {
          "code": "3507190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 31.1416,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 12 5 165812",
      "code_information": [
        {
          "code": "3507192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 14 5 165814",
      "code_information": [
        {
          "code": "3507193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 16 5 165816",
      "code_information": [
        {
          "code": "3507194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 18 5 165818",
      "code_information": [
        {
          "code": "3507195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 20 5 165820",
      "code_information": [
        {
          "code": "3507196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 22 5 165822",
      "code_information": [
        {
          "code": "3507197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 24 5 165824",
      "code_information": [
        {
          "code": "3507198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 144.586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18F 0125RL18",
      "code_information": [
        {
          "code": "3507371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 260,
          "minimum": 81.1906,
          "maximum": 188.682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.3797,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 20F 30C W/V  0125RL20",
      "code_information": [
        {
          "code": "3507373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 105.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.0594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 22FR/30CC",
      "code_information": [
        {
          "code": "3507381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 146.2543,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 24F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 190.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 162.2302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 26F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 36.7026,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 20FR 30CC      266720",
      "code_information": [
        {
          "code": "3507665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.7118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 24FR 30CC      266724",
      "code_information": [
        {
          "code": "3507670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3CC   8887603101",
      "code_information": [
        {
          "code": "3507688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 7.7854,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W  8F  3CC   8887603085",
      "code_information": [
        {
          "code": "3507852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 165.1617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-OXIMETRY 5 LUMEN  5032805",
      "code_information": [
        {
          "code": "3508302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1222,
          "minimum": 399.8359,
          "maximum": 886.8054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 753.7846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SOAKER 1\\\"           PM030",
      "code_information": [
        {
          "code": "3508888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 719,
          "minimum": 90.6443,
          "maximum": 521.7783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 443.5116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-20X1.5 RADIO ARTE RA04220",
      "code_information": [
        {
          "code": "3509147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 32.2538,
          "maximum": 130.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.0321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 16FR  010116",
      "code_information": [
        {
          "code": "3509269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 14FR  010114",
      "code_information": [
        {
          "code": "3509270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN STRAIGHT 18FR",
      "code_information": [
        {
          "code": "3509305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 125.6786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-CHEST DRAIN 9.6FR",
      "code_information": [
        {
          "code": "3509905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 82.8589,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.7629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP ADJ     AA11",
      "code_information": [
        {
          "code": "3509911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 149,
          "minimum": 50.9379,
          "maximum": 108.1293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.9099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-LOW TEMP ADJ      AA02",
      "code_information": [
        {
          "code": "3509912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3510001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.6027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COA 04273",
      "code_information": [
        {
          "code": "3510002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.6786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3510099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEX 72\\\"   DF47x-6121Z",
      "code_information": [
        {
          "code": "3510143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 104.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENTILATOR COAX",
      "code_information": [
        {
          "code": "3510148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.2361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLEANSER-BODY FOAMING REMEDY",
      "code_information": [
        {
          "code": "3510305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCLIP-MEDIUM         523800",
      "code_information": [
        {
          "code": "3510401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.1246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL SMALL 710-SMAL",
      "code_information": [
        {
          "code": "3510714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL MEDIUM 710-MED",
      "code_information": [
        {
          "code": "3510715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 125.5461,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK PEDI-SELE",
      "code_information": [
        {
          "code": "3510817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL ALL SZ A11500x",
      "code_information": [
        {
          "code": "3510830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.4318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3511220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 66.732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.0759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y PRISMAFLEX",
      "code_information": [
        {
          "code": "3511240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISP F/NEOBLUE COZY",
      "code_information": [
        {
          "code": "3511668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.8992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FOOT PNEU LRG PR  VP520L",
      "code_information": [
        {
          "code": "3511672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 99.4209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.5078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FT PNEU REGULAR PR VP520",
      "code_information": [
        {
          "code": "3511673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE LTX-FREE   610-002",
      "code_information": [
        {
          "code": "3511677",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 85.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT MED LF/ALUM  7703",
      "code_information": [
        {
          "code": "3511781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 111.7578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-YOUTH LF/ALUM      7702",
      "code_information": [
        {
          "code": "3511795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 169.0544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3511958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.5209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB TALL",
      "code_information": [
        {
          "code": "3511962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.5209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-WAFFLE 16x16x2  200WCI",
      "code_information": [
        {
          "code": "3512318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 210,
          "minimum": 71.7916,
          "maximum": 152.397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 129.5375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FOAM W/COVER    154264",
      "code_information": [
        {
          "code": "3512506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 211,
          "minimum": 72.1335,
          "maximum": 153.1227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.1543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 16-18FR",
      "code_information": [
        {
          "code": "3512575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.1436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.1CM 9231",
      "code_information": [
        {
          "code": "3512760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.1246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.2CM 9232",
      "code_information": [
        {
          "code": "3512761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 131,
          "minimum": 44.7843,
          "maximum": 95.0667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.8067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ANCHOR PICC LNE PIC0220",
      "code_information": [
        {
          "code": "3512770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.4128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 PED PEDI CAP",
      "code_information": [
        {
          "code": "3512773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 722.93,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RESQPOD 029-12-0242-000",
      "code_information": [
        {
          "code": "3512775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 801.8985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FEMOSTOP         11165",
      "code_information": [
        {
          "code": "3512782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 97.3175,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 804.9827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH STABILIZ    DIO120",
      "code_information": [
        {
          "code": "3512792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH SECURMENT VPPDFP",
      "code_information": [
        {
          "code": "3512794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 82.8589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL  SMALL  S-22MM",
      "code_information": [
        {
          "code": "3513121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 149,
          "minimum": 50.9379,
          "maximum": 108.1293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.9099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL MEDIUM  M-29MM",
      "code_information": [
        {
          "code": "3513123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 921.4577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.0131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-ACCU ANTI-REFLUX INS8401",
      "code_information": [
        {
          "code": "3513202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1657,
          "minimum": 215.7668,
          "maximum": 1202.4849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1022.1122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST VALVE PNEUMOSTAT",
      "code_information": [
        {
          "code": "3513225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 40.0392,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.3359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT PRATT        SU130s",
      "code_information": [
        {
          "code": "3513231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.4128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE W/ISO BAG    1003",
      "code_information": [
        {
          "code": "3513475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 108.4395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM SM SIMP CS",
      "code_information": [
        {
          "code": "3514025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 414,
          "minimum": 141.5321,
          "maximum": 300.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 255.3738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM BRIDGE",
      "code_information": [
        {
          "code": "3514230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 640,
          "minimum": 204.0887,
          "maximum": 464.448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 394.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-PREVENA 45ML",
      "code_information": [
        {
          "code": "3514251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 367,
          "minimum": 125.4644,
          "maximum": 266.3319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 226.3821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC 500ML WITH GEL",
      "code_information": [
        {
          "code": "3514255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 413,
          "minimum": 141.1902,
          "maximum": 299.7141,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 254.757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO MED",
      "code_information": [
        {
          "code": "3514259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1213,
          "minimum": 414.6821,
          "maximum": 880.2741,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 748.233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO SM",
      "code_information": [
        {
          "code": "3514261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 30.5855,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYME 4X4 5044",
      "code_information": [
        {
          "code": "3514264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 106.2151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.9265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM     10X15CM",
      "code_information": [
        {
          "code": "3514272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 138.6087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.8174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDITRACE 31319281**",
      "code_information": [
        {
          "code": "3514650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 917.0089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5FR   006173P",
      "code_information": [
        {
          "code": "3514812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1649,
          "minimum": 116.781,
          "maximum": 1196.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1017.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-REDIPAK",
      "code_information": [
        {
          "code": "3514819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 210,
          "minimum": 71.7916,
          "maximum": 152.397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 129.5375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLOOD        SQ40S",
      "code_information": [
        {
          "code": "3516138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 97.3175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.4888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTERLINE-INTUBATED SET 185",
      "code_information": [
        {
          "code": "3516160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 891.4283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-MR 9GX14CM 20MM",
      "code_information": [
        {
          "code": "3518855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2344,
          "minimum": 318.6453,
          "maximum": 1701.0408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1445.8847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX16CM",
      "code_information": [
        {
          "code": "3518857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 353.4522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX1xCM",
      "code_information": [
        {
          "code": "3518865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 353.4522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX1xCM",
      "code_information": [
        {
          "code": "3518868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX10CM",
      "code_information": [
        {
          "code": "3518870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 578,
          "minimum": 56.7222,
          "maximum": 419.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 356.5364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1962",
      "code_information": [
        {
          "code": "3519300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1034,
          "minimum": 46.7124,
          "maximum": 750.3738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 637.8177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS LF ADLT",
      "code_information": [
        {
          "code": "3519395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUGGER-HEART STERNUM ALL 1000s",
      "code_information": [
        {
          "code": "3519770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 83.9711,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 676.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 12F 36\\\"",
      "code_information": [
        {
          "code": "3520193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.1898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 20F 5CC",
      "code_information": [
        {
          "code": "3520196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 129.5713,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 22FR 20CC",
      "code_information": [
        {
          "code": "3520199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 55.61,
          "maximum": 169.0881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 143.7249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INHALER-DIAMOND SPACR 107-9830",
      "code_information": [
        {
          "code": "3520701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-INTUBATION ALL Gs",
      "code_information": [
        {
          "code": "3521014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1015,
          "minimum": 124.0103,
          "maximum": 736.5855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 626.0977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BARRIER MINOR PROTECTIVE",
      "code_information": [
        {
          "code": "3521441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.1626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT FEMORAL 111644",
      "code_information": [
        {
          "code": "3521442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 115.1127,
          "maximum": 309.1482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 262.776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACOSTOMY PROC ******",
      "code_information": [
        {
          "code": "3521523",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 207,
          "minimum": 70.766,
          "maximum": 664.5395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.6869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH CVP SL       AK-24301",
      "code_information": [
        {
          "code": "3521655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 1142.2294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRAINAL ACCESS    INS-5HND",
      "code_information": [
        {
          "code": "3521683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2054,
          "minimum": 207.4253,
          "maximum": 1490.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1266.9996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DAILY CARE            6638",
      "code_information": [
        {
          "code": "3521745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.4128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAINAGE PLEURX    50-7510",
      "code_information": [
        {
          "code": "3521755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 43.9319,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 508.2803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DURAPREP SURGICAL     8630",
      "code_information": [
        {
          "code": "3521756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 996.5312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HYPOTHERMIA \\\"KOOL KIT\\\" 900",
      "code_information": [
        {
          "code": "3521917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1792,
          "minimum": 226.3327,
          "maximum": 1300.4544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1105.3862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 6FR AK-09601***",
      "code_information": [
        {
          "code": "3521942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 407,
          "minimum": 139.139,
          "maximum": 295.3599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 251.0559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 8.5 AK-09803CDC",
      "code_information": [
        {
          "code": "3521947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 628,
          "minimum": 43.9319,
          "maximum": 455.7396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 387.3787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGAT CONE/TUBE BX  7721",
      "code_information": [
        {
          "code": "3521963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-SARAH 2778 ALL SIZES",
      "code_information": [
        {
          "code": "3522000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 505,
          "minimum": 142.3616,
          "maximum": 366.4785,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 311.5067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-HANNAH 2160 ALL SIZES",
      "code_information": [
        {
          "code": "3522002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 256,
          "minimum": 87.5174,
          "maximum": 185.7792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 157.9123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K ALL SIZES",
      "code_information": [
        {
          "code": "3522003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 707.3592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 177.6514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LUMBAR PUNCTURE    4011015",
      "code_information": [
        {
          "code": "3522152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.3145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MAC CATH MULTI AK-21242CDC",
      "code_information": [
        {
          "code": "3522182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1364,
          "minimum": 392.6066,
          "maximum": 989.8548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.3766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 20FR         6820",
      "code_information": [
        {
          "code": "3522270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 435.4926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00568241",
      "code_information": [
        {
          "code": "3522271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 435.4926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KOOL NEONATAL 950",
      "code_information": [
        {
          "code": "3522460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1169,
          "minimum": 399.64,
          "maximum": 848.3433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 721.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING ALL",
      "code_information": [
        {
          "code": "3522465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 249.1328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.1898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-MORGAN LTX-FREE    MT2000",
      "code_information": [
        {
          "code": "3522687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 448,
          "minimum": 40.0392,
          "maximum": 325.1136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.3466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-4-WAY         4238701",
      "code_information": [
        {
          "code": "3523121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.4128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND PREMATURE 900643",
      "code_information": [
        {
          "code": "3523139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND MICRO     900644",
      "code_information": [
        {
          "code": "3523140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 50MM    RD805-10",
      "code_information": [
        {
          "code": "3523187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 101,
          "minimum": 34.5284,
          "maximum": 2159.8924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MITT-HAND CONTROL PR  M2023V-A",
      "code_information": [
        {
          "code": "3523675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 69.7404,
          "maximum": 365.3577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.8364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTRAOSSEOUS ORANGE",
      "code_information": [
        {
          "code": "3523854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATN     ALL 7700's",
      "code_information": [
        {
          "code": "3523864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 309.1482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 262.776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX11C",
      "code_information": [
        {
          "code": "3525447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 144.0299,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X13.8 C1616A",
      "code_information": [
        {
          "code": "3525465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 88.543,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.7629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X7.8  C1610A",
      "code_information": [
        {
          "code": "3525466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X7.8  C2010A",
      "code_information": [
        {
          "code": "3525467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "3525468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 352.5674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL STR 17GX4-1/2\\\"",
      "code_information": [
        {
          "code": "3525873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 73.9613,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.6596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 20G X 1\\\"",
      "code_information": [
        {
          "code": "3525882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 476.5777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS G04153",
      "code_information": [
        {
          "code": "3525915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 857,
          "minimum": 136.2445,
          "maximum": 621.9249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 528.6362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-4   DJ4011X",
      "code_information": [
        {
          "code": "3525924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 43.9319,
          "maximum": 177.7965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 151.127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL PENCAN    333866",
      "code_information": [
        {
          "code": "3525950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 67.8442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX5\\\"    405148",
      "code_information": [
        {
          "code": "3525951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 88.5354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX7\\\"    405149",
      "code_information": [
        {
          "code": "3525960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X22G",
      "code_information": [
        {
          "code": "3525975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 74.7471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X25G",
      "code_information": [
        {
          "code": "3525976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 418.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PROBLOC 20X100 HN3S-100",
      "code_information": [
        {
          "code": "3526110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 679.5542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E CATH PLUS 241285-41E",
      "code_information": [
        {
          "code": "3526122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 467,
          "minimum": 159.6509,
          "maximum": 537.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 288.0666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PULSAVAC 00-5150-182-00",
      "code_information": [
        {
          "code": "3526127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL EXTEND 480422",
      "code_information": [
        {
          "code": "3526149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3703,
          "minimum": 1265.9256,
          "maximum": 4248.604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2284.177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-AIRWAY EMMA 17448",
      "code_information": [
        {
          "code": "3526175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 166,
          "minimum": 56.7496,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.3963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.5/2.8",
      "code_information": [
        {
          "code": "3526179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1520,
          "minimum": 464.8996,
          "maximum": 1103.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 937.6044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO xxXxxMM 2.0",
      "code_information": [
        {
          "code": "3526182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 639.0514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 5800-8-125",
      "code_information": [
        {
          "code": "3526187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1120,
          "minimum": 382.8886,
          "maximum": 812.784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 690.8664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.3MM TWIST QC",
      "code_information": [
        {
          "code": "3526189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 132.3518,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT,-NIFOMETER 10-340-03",
      "code_information": [
        {
          "code": "3526194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 238,
          "minimum": 63.3954,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 146.8091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-NASAL AUTOMATION MAD300",
      "code_information": [
        {
          "code": "3526195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 70143061",
      "code_information": [
        {
          "code": "3526216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 63.5869,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.7332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT BUTTERFLY 240073",
      "code_information": [
        {
          "code": "3526217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 646.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER SB4000SA",
      "code_information": [
        {
          "code": "3526218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1162,
          "minimum": 397.247,
          "maximum": 843.2634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 716.7739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SB4040SC",
      "code_information": [
        {
          "code": "3526219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1298,
          "minimum": 443.7406,
          "maximum": 941.9586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 800.6648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MALLEABLE MS4000SC",
      "code_information": [
        {
          "code": "3526220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1330,
          "minimum": 99.5419,
          "maximum": 965.181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 820.4038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y936H",
      "code_information": [
        {
          "code": "3526223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 2691.524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CANNULATED 2.0X120MM",
      "code_information": [
        {
          "code": "3526239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1136,
          "minimum": 388.3585,
          "maximum": 9117.8156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 700.7359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICYRL-4-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 7.7854,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X36",
      "code_information": [
        {
          "code": "3526256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 56.7222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X96",
      "code_information": [
        {
          "code": "3526257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 74.0214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-0 PDS PLUS 1X60",
      "code_information": [
        {
          "code": "3526258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.0024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 12X18",
      "code_information": [
        {
          "code": "3526259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-4-0 PLUS 1X18",
      "code_information": [
        {
          "code": "3526264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRILL 2.0 SPEED HAND WRIS",
      "code_information": [
        {
          "code": "3526271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2796,
          "minimum": 955.8541,
          "maximum": 2855.0174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1724.6986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM ANTERIOR",
      "code_information": [
        {
          "code": "3526278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 595,
          "minimum": 203.4096,
          "maximum": 1055.4778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 367.0228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM     70890832",
      "code_information": [
        {
          "code": "3526280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 119,
          "minimum": 40.6819,
          "maximum": 225.7766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 73.4046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT LMA ALL SIZE",
      "code_information": [
        {
          "code": "3526297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURAGAIN SIZE 4",
      "code_information": [
        {
          "code": "3526298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 592.2465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREADED AR-13226T",
      "code_information": [
        {
          "code": "3526314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 930,
          "minimum": 317.9343,
          "maximum": 5759.5277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 573.6658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BATTERY 1.5 50-1010",
      "code_information": [
        {
          "code": "3526343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 919,
          "minimum": 99.5419,
          "maximum": 666.9183,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 566.8806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC SUPER AK-24301-SK",
      "code_information": [
        {
          "code": "3526356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 684,
          "minimum": 233.8356,
          "maximum": 526.0706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 421.922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY 351-3500SZ",
      "code_information": [
        {
          "code": "3526357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 946,
          "minimum": 323.4042,
          "maximum": 53870.5192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 583.5354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 115” Y 1637101",
      "code_information": [
        {
          "code": "3526361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 438.7629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.4888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LITHOTOMY DYNJ31774G",
      "code_information": [
        {
          "code": "3526362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 789,
          "minimum": 269.7314,
          "maximum": 705.6909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 486.6907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER CLOSED 4MM STRT",
      "code_information": [
        {
          "code": "3526366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1269,
          "minimum": 433.8265,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 782.7763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER XPEEDA AC-1000729",
      "code_information": [
        {
          "code": "3526375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAL, X",
      "code_information": [
        {
          "code": "3526388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 528,
          "minimum": 180.5046,
          "maximum": 383.1696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 325.6942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAl LG",
      "code_information": [
        {
          "code": "3526389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 528,
          "minimum": 180.5046,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 325.6942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-METATRSAL 20MM",
      "code_information": [
        {
          "code": "3526404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 757.4082,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.2X1.8X87MM",
      "code_information": [
        {
          "code": "3526414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CANN 2.2 A-2716",
      "code_information": [
        {
          "code": "3526415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2846,
          "minimum": 75.0735,
          "maximum": 2065.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1755.5409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 20GX6 405211",
      "code_information": [
        {
          "code": "3526416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 486.5875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.2741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL 7 SP-78107",
      "code_information": [
        {
          "code": "3526419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1023,
          "minimum": 349.7278,
          "maximum": 742.3911,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 631.0324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-GEN VASCULAR DYNJ60177",
      "code_information": [
        {
          "code": "3526422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1556,
          "minimum": 531.9417,
          "maximum": 1129.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 959.8108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC SIE DYNJ905699",
      "code_information": [
        {
          "code": "3526423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1952,
          "minimum": 667.3202,
          "maximum": 1416.5664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1204.0814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO SHOULDER DYNJ60141",
      "code_information": [
        {
          "code": "3526425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 262.2103,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 473.1201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO KNEE DYNJ60140",
      "code_information": [
        {
          "code": "3526428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 209.905,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 378.7428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-LOW FLOW,DISP PATIENT",
      "code_information": [
        {
          "code": "3526443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HIGH FLOW, DISP PT'",
      "code_information": [
        {
          "code": "3526445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1053,
          "minimum": 35.0343,
          "maximum": 764.1621,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.5378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SMALL PED NASAL OXYGEN",
      "code_information": [
        {
          "code": "3526446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 45.7191,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-PED/ADULT SM – MP1500",
      "code_information": [
        {
          "code": "3526447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 45.7191,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIGH FLOW ADULT MA1700",
      "code_information": [
        {
          "code": "3526449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 11710.9099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INFANT OVER THE EAR",
      "code_information": [
        {
          "code": "3526455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 121.7859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORPEDO-4.0MM X13 CM AR-8400T",
      "code_information": [
        {
          "code": "3526458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 930,
          "minimum": 317.9343,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 573.6658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ABLATOR-ASPIRATING AR-8921",
      "code_information": [
        {
          "code": "3526459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 99.5419,
          "maximum": 985.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 837.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR COLD 10MM Rnd",
      "code_information": [
        {
          "code": "3526467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.3334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-OVAL FLUSH-CUT AR-8550FOS",
      "code_information": [
        {
          "code": "3526471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 486.0739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOLVE-CUT RESIST XL520036000",
      "code_information": [
        {
          "code": "3526473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 281.6966,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 508.2803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE/BLACK 1.5MM",
      "code_information": [
        {
          "code": "3526474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.6824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-90 DEG APOLLO AR-9811",
      "code_information": [
        {
          "code": "3526476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 985.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 837.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELITE IRRIG 5407010470",
      "code_information": [
        {
          "code": "3526484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 478.6717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 12 DPSB 60707010200",
      "code_information": [
        {
          "code": "3526492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPSB 60707010300",
      "code_information": [
        {
          "code": "3526493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.0725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPSB 60707010400",
      "code_information": [
        {
          "code": "3526494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 260.8109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.6621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPDB 60708010300",
      "code_information": [
        {
          "code": "3526495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 340.3533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 289.3003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 260715",
      "code_information": [
        {
          "code": "3526503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TUBING MXB-T",
      "code_information": [
        {
          "code": "3526520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 506,
          "minimum": 172.9836,
          "maximum": 1638.8267,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.1236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-FLOTRAX PERFUSION 84\\\" M",
      "code_information": [
        {
          "code": "3526525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2947,
          "minimum": 497.7095,
          "maximum": 2138.6379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1817.8422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT YG-272T",
      "code_information": [
        {
          "code": "3526528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 1475.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.9016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.5MMX13CM AR-8550EX",
      "code_information": [
        {
          "code": "3526571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BULLET CUTTING 3MM",
      "code_information": [
        {
          "code": "3526591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2519,
          "minimum": 861.1576,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1553.8326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MAJOR HEAD/NEC DYNJ38985A",
      "code_information": [
        {
          "code": "3526665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 696,
          "minimum": 237.9379,
          "maximum": 1426.9526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 429.3241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-BIOPATCH CHG 1”X4MM 4150",
      "code_information": [
        {
          "code": "3526904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 10956.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-JAW TISSUE ENSEAL LRG",
      "code_information": [
        {
          "code": "3526926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2829,
          "minimum": 967.1357,
          "maximum": 3864.895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1745.0545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT SMALL",
      "code_information": [
        {
          "code": "3526929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 571,
          "minimum": 195.2048,
          "maximum": 414.3747,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 352.2185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT LARGE",
      "code_information": [
        {
          "code": "3526930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 660,
          "minimum": 225.6308,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 407.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A443",
      "code_information": [
        {
          "code": "3526935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 393,
          "minimum": 134.3529,
          "maximum": 285.2001,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 242.4201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A445",
      "code_information": [
        {
          "code": "3526936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.3359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFX 2-0 SXMP1B413",
      "code_information": [
        {
          "code": "3526938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 352,
          "minimum": 120.3364,
          "maximum": 336.9966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 217.1294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4FUSION 2.0 CALIBRATED",
      "code_information": [
        {
          "code": "3526943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1113,
          "minimum": 380.4956,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 686.5485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-AFFINITY MANIFOLD 1S85R1",
      "code_information": [
        {
          "code": "3526965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COMP SPEEDARC 11X15X13MM",
      "code_information": [
        {
          "code": "3526978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5134,
          "minimum": 1755.1342,
          "maximum": 3725.7438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3166.8822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7.5CM POST",
      "code_information": [
        {
          "code": "3526995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 608,
          "minimum": 207.8538,
          "maximum": 1044.9119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 375.0418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING DISP EXT 5450850003",
      "code_information": [
        {
          "code": "3526996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1879,
          "minimum": 233.0059,
          "maximum": 1363.5903,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1159.0518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINDER-DISP SUCT CAN",
      "code_information": [
        {
          "code": "3526997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 419,
          "minimum": 143.2414,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 258.4581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIAMETER-STRAIGHT 5450800309",
      "code_information": [
        {
          "code": "3526999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3756,
          "minimum": 1284.0444,
          "maximum": 2725.7292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2316.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRICOTHYROIDOTOMY EMERGENT",
      "code_information": [
        {
          "code": "3527020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1028,
          "minimum": 310.3038,
          "maximum": 746.0196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 634.1167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-2.7MM 311.26",
      "code_information": [
        {
          "code": "3527056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 864,
          "minimum": 295.3712,
          "maximum": 627.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 532.9541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.15, 1.5MM",
      "code_information": [
        {
          "code": "3527057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 283.0641,
          "maximum": 600.8796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.7477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.19, 2.0MM",
      "code_information": [
        {
          "code": "3527058",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 849,
          "minimum": 290.2433,
          "maximum": 1353.5474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 523.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X .75”",
      "code_information": [
        {
          "code": "3527066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 4611.1812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.35X50X101MM",
      "code_information": [
        {
          "code": "3527084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 2087.0433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 639.0514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PICK-VEIN 6541",
      "code_information": [
        {
          "code": "3527102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.0/2.3",
      "code_information": [
        {
          "code": "3527119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1520,
          "minimum": 519.6346,
          "maximum": 1103.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 937.6044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO",
      "code_information": [
        {
          "code": "3527121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 53.9417,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 639.0514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BRUSH ALGER 0.5MM",
      "code_information": [
        {
          "code": "3527123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOPATCH-DRESS CHG 1” X 7MM",
      "code_information": [
        {
          "code": "3527124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 2416.2545,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLENOID DRILL 2.5MM",
      "code_information": [
        {
          "code": "3527142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8074,
          "minimum": 2760.2169,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4980.4065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD WIDE MT-APUW",
      "code_information": [
        {
          "code": "3527145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 287.4498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLUS-VIVAER ARC DISP CAT500",
      "code_information": [
        {
          "code": "3527147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9026,
          "minimum": 870.8526,
          "maximum": 6550.1682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5567.643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-KEITH FREE 1827-2.5DC",
      "code_information": [
        {
          "code": "3527159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3MM AR-8930D-13",
      "code_information": [
        {
          "code": "3527163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 83.415,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-GONIO SURG OSIG",
      "code_information": [
        {
          "code": "3527169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 4705.7182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO V4608-20",
      "code_information": [
        {
          "code": "3527175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.1519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 3.2X125MM GRAY",
      "code_information": [
        {
          "code": "3527179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1195,
          "minimum": 408.5285,
          "maximum": 1627.1486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 737.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-POSEY SECURE INFANT PED",
      "code_information": [
        {
          "code": "3527200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 389,
          "minimum": 132.9854,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.9527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-INDIGO 140CM CATRXKIT",
      "code_information": [
        {
          "code": "3527201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8123,
          "minimum": 2588.0894,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5010.6319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPERATOR-C4 PENUMBRA SEPC4",
      "code_information": [
        {
          "code": "3527202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4654,
          "minimum": 1343.5376,
          "maximum": 3377.4078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2870.7966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENGINE INDIGO IAPS3",
      "code_information": [
        {
          "code": "3527203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 259.1426,
          "maximum": 1753.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1490.2975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRVO2-TUBE CHAMBER KIT, 900PT",
      "code_information": [
        {
          "code": "3527205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 730,
          "minimum": 249.5613,
          "maximum": 5082.1979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 450.2969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN W/AO 5.0MM",
      "code_information": [
        {
          "code": "3527232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 9536.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 301.0204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-QUICK CONN DRVR-UQC-T10",
      "code_information": [
        {
          "code": "3527241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1399,
          "minimum": 478.2689,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.9662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7X70MM IJS-CDC-2770",
      "code_information": [
        {
          "code": "3527242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2785,
          "minimum": 952.0936,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.9133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSSEPTAL NTK-711-8545",
      "code_information": [
        {
          "code": "3527245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 81.1906,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERES-PASSIVE 8801075",
      "code_information": [
        {
          "code": "3527246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.0594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.9X10X61MM",
      "code_information": [
        {
          "code": "3527253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 639.0514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DRILL SELF HOLD",
      "code_information": [
        {
          "code": "3527257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2110,
          "minimum": 721.3349,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1301.543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE 108984",
      "code_information": [
        {
          "code": "3527264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO MICRO 0",
      "code_information": [
        {
          "code": "3527266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 649,
          "minimum": 221.8703,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 400.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3527268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5424,
          "minimum": 311.9721,
          "maximum": 3936.1968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3345.7673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-STERILE PGH 396985",
      "code_information": [
        {
          "code": "3527269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-BS IS-1 330834",
      "code_information": [
        {
          "code": "3527270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 7MM, 70X",
      "code_information": [
        {
          "code": "3527281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 436.1094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-301-CG 343586",
      "code_information": [
        {
          "code": "3527282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIDER TS101DC",
      "code_information": [
        {
          "code": "3527287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 594,
          "minimum": 99.5419,
          "maximum": 431.0658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 366.4059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM 7089-0832",
      "code_information": [
        {
          "code": "3527289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 88.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 1.27MM",
      "code_information": [
        {
          "code": "3527290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 5375.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.6952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER DS2C026",
      "code_information": [
        {
          "code": "3527342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4316,
          "minimum": 208.5375,
          "maximum": 3132.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2662.303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ALLEN 3.0MM 904-0030",
      "code_information": [
        {
          "code": "3527343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 375,
          "minimum": 128.1993,
          "maximum": 4835.2895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.3169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3527395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 97.9695,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.2741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAXI-THERM LITE 871*******",
      "code_information": [
        {
          "code": "3527520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-CALAZIME REMEDY 4 OZ",
      "code_information": [
        {
          "code": "3527567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 1897.9693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-K SOFT 117464",
      "code_information": [
        {
          "code": "3527806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 60-S FIRM 119291",
      "code_information": [
        {
          "code": "3527807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-C MEDIUM 342657",
      "code_information": [
        {
          "code": "3527808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 11365.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 03.033.004",
      "code_information": [
        {
          "code": "3527874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 109.5517,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-INFANT POSITIONER",
      "code_information": [
        {
          "code": "3527875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 27745.4973,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.5185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CRM DYNJ62070",
      "code_information": [
        {
          "code": "3527887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 756,
          "minimum": 258.4498,
          "maximum": 548.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 466.3348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-INFANT FULL BODY",
      "code_information": [
        {
          "code": "3527890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1059,
          "minimum": 362.0349,
          "maximum": 970.9506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 653.2389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNCK SLCT980010",
      "code_information": [
        {
          "code": "3527947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-IRR SUCT 5500-573-000",
      "code_information": [
        {
          "code": "3527977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3127,
          "minimum": 331.9917,
          "maximum": 2269.2639,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1928.8743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION 5450-851-012",
      "code_information": [
        {
          "code": "3527978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 2832.7734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MICRO-IQ 12CM 5500-25S-309",
      "code_information": [
        {
          "code": "3527979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5094,
          "minimum": 1741.4596,
          "maximum": 3696.7158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3142.2084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STD-12CM 5500-25S-307",
      "code_information": [
        {
          "code": "3527980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4754,
          "minimum": 1625.2255,
          "maximum": 3449.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2932.4811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRACUDA-12CM IQ 5500-25S-310",
      "code_information": [
        {
          "code": "3527981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5201,
          "minimum": 317.5331,
          "maximum": 3774.3657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3208.2108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-APEX 11CM 5500-25B-114",
      "code_information": [
        {
          "code": "3527983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 342.0015,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND ROYLAN RT MED",
      "code_information": [
        {
          "code": "3528086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 1014.8825,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORTHOSIS-ANKLE FOOT LG",
      "code_information": [
        {
          "code": "3528101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 704,
          "minimum": 240.6729,
          "maximum": 720.1495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 434.2589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 30 DPSB 60707010500",
      "code_information": [
        {
          "code": "3529495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPDB 60708010200",
      "code_information": [
        {
          "code": "3529498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 428,
          "minimum": 146.3182,
          "maximum": 354.2357,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 264.0097,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SINGLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 637,
          "minimum": 217.7679,
          "maximum": 462.2709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 392.9303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST DOUBLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 468,
          "minimum": 159.9928,
          "maximum": 430.4214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 288.6835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #4     4DCP",
      "code_information": [
        {
          "code": "3533309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #6,8,10 DCP",
      "code_information": [
        {
          "code": "3533315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SKIN TEMP DISP MU11228",
      "code_information": [
        {
          "code": "3533577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP ISOLETTE    MU12551",
      "code_information": [
        {
          "code": "3533578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 238,
          "minimum": 51.1612,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 146.8091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-RECTAL/ESOPH ST     491B",
      "code_information": [
        {
          "code": "3533590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTANT-SKIN REMEDY 2 OZ",
      "code_information": [
        {
          "code": "3536085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 78.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-SKIN NO STING    MSC1528",
      "code_information": [
        {
          "code": "3536099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 142,
          "minimum": 48.5448,
          "maximum": 103.0494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-EYE FOAM       28300",
      "code_information": [
        {
          "code": "3536100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 957.0481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-JP 100ML  SU130-1305",
      "code_information": [
        {
          "code": "3538200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3539345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 197.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INITIATION BREAST MILK 673",
      "code_information": [
        {
          "code": "3539346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 356,
          "minimum": 111.22,
          "maximum": 258.3492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 219.5968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-MANUAL HARMONY 67186S",
      "code_information": [
        {
          "code": "3539347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-BIS QUATTRO    186-0106",
      "code_information": [
        {
          "code": "3541300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 336,
          "minimum": 114.8666,
          "maximum": 243.8352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 207.2599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS PED DISP",
      "code_information": [
        {
          "code": "3541324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS ADLT DISP",
      "code_information": [
        {
          "code": "3541325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SKIN HNICU38",
      "code_information": [
        {
          "code": "3541328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 187.4057,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.3096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RECIP PLATELET     4C-2100",
      "code_information": [
        {
          "code": "3541430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 116.112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.6952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD FILTRATION   4020005",
      "code_information": [
        {
          "code": "3541446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 140.1372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.2931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BURETROL 150ML",
      "code_information": [
        {
          "code": "3541503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 252,
          "minimum": 86.1499,
          "maximum": 2947.8861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 155.4449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW RADIAL ARTERY",
      "code_information": [
        {
          "code": "3541912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.7794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP Y FOR BLOOD IV  D-100",
      "code_information": [
        {
          "code": "3541945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 162.3812,
          "maximum": 618.2964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 525.5519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DIALYZER EXELTRA    5M2119",
      "code_information": [
        {
          "code": "3541947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 292,
          "minimum": 99.8245,
          "maximum": 855.8379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 180.1187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3541950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1539,
          "minimum": 365.3577,
          "maximum": 1116.8523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 949.3245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FEMORAL ART  C-PMS-401J-FA",
      "code_information": [
        {
          "code": "3542127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 828.0329,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO ALL SZ W/ STABILIZER",
      "code_information": [
        {
          "code": "3542128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1489,
          "minimum": 509.0368,
          "maximum": 1250.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 918.4822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER HF 1000 PRISMAFLEX",
      "code_information": [
        {
          "code": "3542131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2248,
          "minimum": 99.5419,
          "maximum": 1631.3736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1386.6676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 110 INFUSION 1635101",
      "code_information": [
        {
          "code": "3542760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 1262.9031,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.1898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRISMAFLEX TPE2000 114093",
      "code_information": [
        {
          "code": "3542806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2271,
          "minimum": 99.5419,
          "maximum": 1648.0647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1400.855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RADIAL ARTERY C-PMS-301-RA",
      "code_information": [
        {
          "code": "3543008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 61.171,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORACENTESIS      4653-48",
      "code_information": [
        {
          "code": "3543530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TUR IRRIGATION  06543-01",
      "code_information": [
        {
          "code": "3543551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 596.6953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE REPOSITION",
      "code_information": [
        {
          "code": "3543681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 497,
          "minimum": 169.9068,
          "maximum": 440.4312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 306.572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE XL REPOSITION",
      "code_information": [
        {
          "code": "3543685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 38.3709,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 488.5412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE SM   2042-01",
      "code_information": [
        {
          "code": "3543730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 126.7908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE LRG  2042-03",
      "code_information": [
        {
          "code": "3543732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 63.9515,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-NIPPLE REGULAR   67203S",
      "code_information": [
        {
          "code": "3544003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 92.3126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SEQ COMP KNEE      95xx",
      "code_information": [
        {
          "code": "3544619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 150.9456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.3038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501B",
      "code_information": [
        {
          "code": "3544638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.0701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501L",
      "code_information": [
        {
          "code": "3544639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 121.1919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.0131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE   VP501M",
      "code_information": [
        {
          "code": "3544640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 114.5566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.2931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530M",
      "code_information": [
        {
          "code": "3544645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.0701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530L",
      "code_information": [
        {
          "code": "3544650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 31.6977,
          "maximum": 164.0082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM CHILD        8001-01",
      "code_information": [
        {
          "code": "3544659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 41.3649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ELEVATOR     8011-02",
      "code_information": [
        {
          "code": "3544860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE ALL SZS TX4442-0x",
      "code_information": [
        {
          "code": "3545160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 92.8896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE PED       9007-00",
      "code_information": [
        {
          "code": "3545177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 299.7379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.9751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 3L   5B9858",
      "code_information": [
        {
          "code": "3545500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 539,
          "minimum": 184.2652,
          "maximum": 391.1523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 332.4795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 3L  5B9859",
      "code_information": [
        {
          "code": "3545502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 557,
          "minimum": 190.4187,
          "maximum": 404.2149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 343.5827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 2L  5B9896",
      "code_information": [
        {
          "code": "3545504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 501,
          "minimum": 171.2743,
          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.0393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 2L   5B9876",
      "code_information": [
        {
          "code": "3545505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 274.496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIAL 1.5% 3L       5B9857",
      "code_information": [
        {
          "code": "3545515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 529,
          "minimum": 32.2538,
          "maximum": 383.8953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 326.311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 1000ML  07139-09",
      "code_information": [
        {
          "code": "3545555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 2000ML  07973-07",
      "code_information": [
        {
          "code": "3545613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 73.8428,
          "maximum": 156.7512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.2385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-GYLCINE 1.5% IRRIG 3000ML",
      "code_information": [
        {
          "code": "3545747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.0701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML  07972-08",
      "code_information": [
        {
          "code": "3545751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 71.4498,
          "maximum": 151.6713,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.9206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 3000ML 07828-08",
      "code_information": [
        {
          "code": "3545752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 35.5904,
          "maximum": 151.6713,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.9206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML R5200-01",
      "code_information": [
        {
          "code": "3545753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 50.049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 1000ML 07953-09",
      "code_information": [
        {
          "code": "3545755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.0294,
          "maximum": 65.313,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 500ML R5201-01",
      "code_information": [
        {
          "code": "3545852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 39.1878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.3096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-MDI ADAPTER INLINE",
      "code_information": [
        {
          "code": "3545901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.0MM 2883-02-040",
      "code_information": [
        {
          "code": "3547925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3131.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-BENDING 03.501.072",
      "code_information": [
        {
          "code": "3547929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1032,
          "minimum": 352.8045,
          "maximum": 4743.533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 636.584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 650.010",
      "code_information": [
        {
          "code": "3547941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM 60XL",
      "code_information": [
        {
          "code": "3547946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 231.1006,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 416.9872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIXER-CEMENT 3CC 658.969S",
      "code_information": [
        {
          "code": "3547948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.601S",
      "code_information": [
        {
          "code": "3547949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ULTRA ACCESS 658.902S",
      "code_information": [
        {
          "code": "3547952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5359,
          "minimum": 696.7933,
          "maximum": 3889.0263,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3305.6724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC M6275009/10",
      "code_information": [
        {
          "code": "3547958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-QUILL 2-0 YA-2034Q",
      "code_information": [
        {
          "code": "3547961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 336,
          "minimum": 114.8666,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 207.2599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-4-0 PROLENE 8526H",
      "code_information": [
        {
          "code": "3547969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 375.9236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT",
      "code_information": [
        {
          "code": "3547970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 221.3278,
          "maximum": 490.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 416.9872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX",
      "code_information": [
        {
          "code": "3547971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 398,
          "minimum": 136.0622,
          "maximum": 320.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 245.5043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY UNCUFF",
      "code_information": [
        {
          "code": "3547972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 355.3027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 2MM AR-7523",
      "code_information": [
        {
          "code": "3547986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-ZONE NAVIGATOR AR-7900",
      "code_information": [
        {
          "code": "3547987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 207.4253,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 650.112",
      "code_information": [
        {
          "code": "3547990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2992.9302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX CN",
      "code_information": [
        {
          "code": "3547997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 354.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 301.0204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX UN",
      "code_information": [
        {
          "code": "3547998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 402,
          "minimum": 31.1416,
          "maximum": 291.7314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 247.9717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SHILEY",
      "code_information": [
        {
          "code": "3547999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 373.1431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY CUFFED",
      "code_information": [
        {
          "code": "3548000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 671,
          "minimum": 229.3913,
          "maximum": 486.9447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 413.903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED  4LPC",
      "code_information": [
        {
          "code": "3548001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 626,
          "minimum": 67.2881,
          "maximum": 454.2882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 386.145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ4 S",
      "code_information": [
        {
          "code": "3548003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 121,
          "minimum": 37.2587,
          "maximum": 87.8097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-TRACH 15MM DECANN WHITE",
      "code_information": [
        {
          "code": "3548004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-TRACH SZ 1 DECANN SH",
      "code_information": [
        {
          "code": "3548005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 433.758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.9265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED",
      "code_information": [
        {
          "code": "3548006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 780,
          "minimum": 31.1416,
          "maximum": 566.046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 481.1391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY FLEX INNER",
      "code_information": [
        {
          "code": "3548007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 67.2881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FLUENT DISP FLT-112",
      "code_information": [
        {
          "code": "3548028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1739,
          "minimum": 594.503,
          "maximum": 1638.8267,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1072.6935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRESSING CHANGE 76681",
      "code_information": [
        {
          "code": "3549001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 275,
          "minimum": 94.0128,
          "maximum": 279.1622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEELIFT-AFO  081531532",
      "code_information": [
        {
          "code": "3549018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 842,
          "minimum": 287.8502,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 519.3835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-SUCTION NEURO NST031/25",
      "code_information": [
        {
          "code": "3549020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-SHANK MOD 5",
      "code_information": [
        {
          "code": "3549027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-LORDOTIC 5",
      "code_information": [
        {
          "code": "3549030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 15838.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1448.9689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KVLAB3C",
      "code_information": [
        {
          "code": "3549037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 116.8377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 99.312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPEN 279726500",
      "code_information": [
        {
          "code": "3549047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3029,
          "minimum": 1035.5087,
          "maximum": 2198.1453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1868.4235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX ER VALVE REPLACEMEN",
      "code_information": [
        {
          "code": "3549059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 180.7325,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX CATH ACCESS 50-7280",
      "code_information": [
        {
          "code": "3549060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 200.4746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-NAVIGATION 286750210S",
      "code_information": [
        {
          "code": "3549063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1656.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 020 XFR004xxx",
      "code_information": [
        {
          "code": "3549066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2903,
          "minimum": 992.4337,
          "maximum": 2273.3368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1790.701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL SND1T3 20.5",
      "code_information": [
        {
          "code": "3549069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5049,
          "minimum": 1726.0757,
          "maximum": 3664.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3114.4504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-SYNC DISTAL RADIAL, SDRB-",
      "code_information": [
        {
          "code": "3549082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 250.4391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-FEMORAL AUG SZ6 154906002",
      "code_information": [
        {
          "code": "3549097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- LIGHT 03.612.021S",
      "code_information": [
        {
          "code": "3549135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2191,
          "minimum": 749.0259,
          "maximum": 1590.0087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1351.5074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LIGHT 03.615.132S",
      "code_information": [
        {
          "code": "3549136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1748,
          "minimum": 597.5798,
          "maximum": 1268.5236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1078.2451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 388.175",
      "code_information": [
        {
          "code": "3549150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1078,
          "minimum": 368.5303,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 664.9589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 9-0 V449G",
      "code_information": [
        {
          "code": "3549155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.7059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHALANGEAL 20MM",
      "code_information": [
        {
          "code": "3549160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADER-TRIAL DRG 7032ANS",
      "code_information": [
        {
          "code": "3549166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1656.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL PRP ABS-10061T",
      "code_information": [
        {
          "code": "3549185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1345.3389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.021S",
      "code_information": [
        {
          "code": "3549190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2362,
          "minimum": 807.4848,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1456.9879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703713",
      "code_information": [
        {
          "code": "3549201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1043.7017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TAP 12.5MM 338.17",
      "code_information": [
        {
          "code": "3549204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1648.8267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- CANN 6.5MM 702603",
      "code_information": [
        {
          "code": "3549216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2032,
          "minimum": 580.0123,
          "maximum": 1474.6224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1253.429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CSG WORLEY STANDARD",
      "code_information": [
        {
          "code": "3549218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1900,
          "minimum": 649.5432,
          "maximum": 1378.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1172.0055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-UNCUFFED 7.0 70XLTUP",
      "code_information": [
        {
          "code": "3549227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 231.1006,
          "maximum": 1146.6782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 416.9872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.1X87 A-3836",
      "code_information": [
        {
          "code": "3549229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CROSS PLATE 705172",
      "code_information": [
        {
          "code": "3549243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2762,
          "minimum": 944.2307,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1703.7259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL CPRP ABS-10063",
      "code_information": [
        {
          "code": "3549250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1980,
          "minimum": 676.8924,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1221.3531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-THREAD LOCK 03.835.009S",
      "code_information": [
        {
          "code": "3549252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1698,
          "minimum": 491.0363,
          "maximum": 1232.2386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1047.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPEEDGUIDE-T8 2.4/2.7X30MM",
      "code_information": [
        {
          "code": "3549269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2408,
          "minimum": 823.2106,
          "maximum": 3101.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1485.3628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEEDGUIDE AO 2.0X30MM",
      "code_information": [
        {
          "code": "3549270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5577,
          "minimum": 249.1328,
          "maximum": 4047.2289,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3440.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 2.1MM",
      "code_information": [
        {
          "code": "3549272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1742,
          "minimum": 595.5286,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1074.544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS TRIPLE 91429",
      "code_information": [
        {
          "code": "3549278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 453,
          "minimum": 154.8648,
          "maximum": 1347.4303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 279.4308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.1X300MM RMT3130",
      "code_information": [
        {
          "code": "3549279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2423,
          "minimum": 575.0074,
          "maximum": 1758.3711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1494.6154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-2.5 SOLID HT-2502",
      "code_information": [
        {
          "code": "3549283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 71.1808,
          "maximum": 1091.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 927.7349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-DHS REAMER 338.13",
      "code_information": [
        {
          "code": "3549287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7319,
          "minimum": 1455.3137,
          "maximum": 5311.3983,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4514.6886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-PALM ROLYAN SOFT GEL LT",
      "code_information": [
        {
          "code": "3549295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 246,
          "minimum": 84.0988,
          "maximum": 178.5222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 151.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FORCEP SUCTION 9G12R",
      "code_information": [
        {
          "code": "3549304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 6512.4871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CATH LINE 020378801",
      "code_information": [
        {
          "code": "3549311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 3739.2164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM 6149.1035",
      "code_information": [
        {
          "code": "3549338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 265.8158,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 650.114",
      "code_information": [
        {
          "code": "3549348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ANGLE 14MM 684.434",
      "code_information": [
        {
          "code": "3549349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 16MM 650.116",
      "code_information": [
        {
          "code": "3549372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 804.9827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP 2.4MM",
      "code_information": [
        {
          "code": "3549451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB LARGE AR-8970-09",
      "code_information": [
        {
          "code": "3549452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 869.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ADAPTER BIOPSY MAJ-1414",
      "code_information": [
        {
          "code": "3549507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 35676.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-THUMB SPICA ANY    350S",
      "code_information": [
        {
          "code": "3549700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 578.9001,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.1898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUICKCLOT 8X8 4010",
      "code_information": [
        {
          "code": "3549703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 642.1356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-COMFY FINGER",
      "code_information": [
        {
          "code": "3549716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 405.3969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 6 6SIC",
      "code_information": [
        {
          "code": "3549725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 89.2611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 8 8SIC",
      "code_information": [
        {
          "code": "3549726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 14374.0728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUIKCLOT 5X5 4000",
      "code_information": [
        {
          "code": "3549730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 733,
          "minimum": 250.5869,
          "maximum": 531.9381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 452.1474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOCN0346",
      "code_information": [
        {
          "code": "3549731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 261.5266,
          "maximum": 1829.0129,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 471.8864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 200 AC-10030100",
      "code_information": [
        {
          "code": "3549732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3289,
          "minimum": 7.7854,
          "maximum": 2386.8273,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2028.8032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ESOPHAGEAL 100001",
      "code_information": [
        {
          "code": "3549734",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 337.5527,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1635.2561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BV175-6 BLUE EPM8743",
      "code_information": [
        {
          "code": "3549735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 607,
          "minimum": 207.512,
          "maximum": 1436.9624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 374.4249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 365 AC-10030110",
      "code_information": [
        {
          "code": "3549736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1593.9275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LONG TUNNELING SC-4254",
      "code_information": [
        {
          "code": "3549742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 2490.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1242.3258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM 03.010.061",
      "code_information": [
        {
          "code": "3549747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1751,
          "minimum": 598.6054,
          "maximum": 2885.6029,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1080.0956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 16MM 03.037.002",
      "code_information": [
        {
          "code": "3549748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5189,
          "minimum": 1773.9368,
          "maximum": 3765.6573,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3200.8087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 6-9MM 03.037.022",
      "code_information": [
        {
          "code": "3549750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3479,
          "minimum": 112.3322,
          "maximum": 2524.7103,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2146.0038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-BABYFLOW PLUS S DISP MP37",
      "code_information": [
        {
          "code": "3549751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.6027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-DISP",
      "code_information": [
        {
          "code": "3549752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 178,
          "minimum": 60.8519,
          "maximum": 129.1746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 109.7984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEOMASK-CPAP",
      "code_information": [
        {
          "code": "3549753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 142.2372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.9016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BABUFLOE SZ 4 DISP MP0149",
      "code_information": [
        {
          "code": "3549754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 225,
          "minimum": 76.9196,
          "maximum": 163.2825,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.7901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP",
      "code_information": [
        {
          "code": "3549755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.0321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PNEUMOTHORAX G05297",
      "code_information": [
        {
          "code": "3549757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1013,
          "minimum": 200.196,
          "maximum": 735.1341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 624.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOURNIQUET-TACTICAL 30-0023",
      "code_information": [
        {
          "code": "3549759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 360,
          "minimum": 123.0713,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.0642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R001",
      "code_information": [
        {
          "code": "3549765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 1875.2088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1593.9275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-A003",
      "code_information": [
        {
          "code": "3549766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 601.7002,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1966.5019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-SEATTLE PLUS MP02260",
      "code_information": [
        {
          "code": "3549776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 99.5419,
          "maximum": 409.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.9006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-DISTAL 24MM 03.211.024",
      "code_information": [
        {
          "code": "3549786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 902.5232,
          "maximum": 1915.848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1628.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PROX 24MM 03.211.124",
      "code_information": [
        {
          "code": "3549787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 902.5232,
          "maximum": 3736.4359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1628.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROCESSOR-SOUND LINE 90711",
      "code_information": [
        {
          "code": "3549810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 141.2494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-BAHA STORAGE Z342010",
      "code_information": [
        {
          "code": "3549811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 2902.2859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.6786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-PERFORM REV PERI MWJ126",
      "code_information": [
        {
          "code": "3549818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5X220MM DWD017",
      "code_information": [
        {
          "code": "3549819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 950,
          "minimum": 324.7716,
          "maximum": 3199.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 586.0027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SHAFT 8X510 0227-8510S",
      "code_information": [
        {
          "code": "3549851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1867,
          "minimum": 638.2617,
          "maximum": 2859.4662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1151.6496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LOCKING 705078",
      "code_information": [
        {
          "code": "3549854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1563,
          "minimum": 534.3348,
          "maximum": 1251.7811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 964.1287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 700354",
      "code_information": [
        {
          "code": "3549867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1228,
          "minimum": 419.81,
          "maximum": 891.1596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 757.4857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW INFINITY 3600315",
      "code_information": [
        {
          "code": "3549870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 2635.3579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 772.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.4 G3606010",
      "code_information": [
        {
          "code": "3549873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 2635.3579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-STRAIGH TIP 2762-01-0004",
      "code_information": [
        {
          "code": "3549916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 1078.5836,
          "maximum": 9858.5408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1946.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR NIM 945NSD2750",
      "code_information": [
        {
          "code": "3549918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 10600.3782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2049.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAGITTAL 2296-003-155",
      "code_information": [
        {
          "code": "3549927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 417.6311,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.3359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 2.4 1608-006-147",
      "code_information": [
        {
          "code": "3549928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 751,
          "minimum": 256.7405,
          "maximum": 545.0007,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 463.2506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 1MM 1608-006-151",
      "code_information": [
        {
          "code": "3549929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 722,
          "minimum": 207.4253,
          "maximum": 523.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.3621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-413S1",
      "code_information": [
        {
          "code": "3549931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 289.7281,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.3359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 7X15MM 2296-003-103",
      "code_information": [
        {
          "code": "3549932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 178.1116,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 321.3762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-111S5",
      "code_information": [
        {
          "code": "3549933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.3359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHORT 2.5MM 2296-003-413",
      "code_information": [
        {
          "code": "3549934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 501,
          "minimum": 125.6786,
          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.0393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48X70MM 2108-197-00S4",
      "code_information": [
        {
          "code": "3549935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 77.2615,
          "maximum": 409.8457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X75MM 4125-089-075",
      "code_information": [
        {
          "code": "3549936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 737,
          "minimum": 251.9544,
          "maximum": 534.8409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 454.6148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90 4125-097-090",
      "code_information": [
        {
          "code": "3549937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 434.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 369.4902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 13X90MM 4113-119-090",
      "code_information": [
        {
          "code": "3549938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 434.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 369.4902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-119-090",
      "code_information": [
        {
          "code": "3549939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 262.2103,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 473.1201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-127-090",
      "code_information": [
        {
          "code": "3549940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 262.2103,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 473.1201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-70X12.5MM 0277-096-277",
      "code_information": [
        {
          "code": "3549941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 572,
          "minimum": 195.5467,
          "maximum": 415.1004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 352.8353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RECIPR. 0277-096-325",
      "code_information": [
        {
          "code": "3549942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 583,
          "minimum": 199.3072,
          "maximum": 462.6752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 359.6206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 6125-119-090",
      "code_information": [
        {
          "code": "3549943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 832,
          "minimum": 284.4316,
          "maximum": 603.7824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 513.215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-18.5X90.5 2108-382-003",
      "code_information": [
        {
          "code": "3549944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 618,
          "minimum": 211.2725,
          "maximum": 11930.0133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 381.2102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE,SAW VASC 5400-134-415",
      "code_information": [
        {
          "code": "3549951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 685,
          "minimum": 234.1774,
          "maximum": 1138.3367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 422.5388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE, SAW 25X90MM 6725-127-09",
      "code_information": [
        {
          "code": "3549952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2047,
          "minimum": 699.7974,
          "maximum": 2788.8415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1262.6817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 8MM M0013635",
      "code_information": [
        {
          "code": "3549961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4128,
          "minimum": 155.708,
          "maximum": 2995.6896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2546.3362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SPINAL W/EPI & BUPIV 3338",
      "code_information": [
        {
          "code": "3549962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 949.8188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 172.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-VISTASEAL VSTL35",
      "code_information": [
        {
          "code": "3549965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 819,
          "minimum": 279.9873,
          "maximum": 31619.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 505.1961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SUTURE UCL AR-7715-4.5",
      "code_information": [
        {
          "code": "3549968",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3921,
          "minimum": 1340.4521,
          "maximum": 46414.3304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2418.6492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-SPIN ACCESS INS-5900",
      "code_information": [
        {
          "code": "3550000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 774.0912,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-75MM 00-5901-020-00",
      "code_information": [
        {
          "code": "3550017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2485,
          "minimum": 849.5342,
          "maximum": 11710.9099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1532.8598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-TIB 42-5320-064-02",
      "code_information": [
        {
          "code": "3550019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9296,
          "minimum": 3177.9757,
          "maximum": 11905.5449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5734.1911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-REVERSED GLEN MWJ004",
      "code_information": [
        {
          "code": "3550025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1242.3258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-PRESS FIT REV DWJ002",
      "code_information": [
        {
          "code": "3550026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 207.4253,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1656.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DSIP RFID EXPIRATORY MP0",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 108.713,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC D-BLADE",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 106.32,
          "maximum": 225.6927,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #3 MILLER",
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        {
          "code": "3550049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 82.7313,
          "maximum": 579.4562,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WALKER-CAM  II 55988503",
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        {
          "code": "3550050",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 356.2232,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-2.5X7MM AR-8998DS",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 710.737,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 PC-5",
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        {
          "code": "3550066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 22.2212,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 18\\\" PC-3",
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        {
          "code": "3550067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 22.9049,
          "maximum": 5332.999,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "PROS-NASAL SEPTAL ROUND SP1102",
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        {
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        },
        {
          "code": "0270",
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 631.0825,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.007.01S",
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        {
          "code": "3550083",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 704.2416,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP LRG 47800100",
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        {
          "code": "3550087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 665.6109,
          "maximum": 1412.9379,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1200.9972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP REG 47700100",
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        {
          "code": "3550088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 585.2726,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1056.0386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP SLIM 4760010",
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        {
          "code": "3550089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 62.8393,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1056.0386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CAN 190MM 03.010.036",
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        {
          "code": "3550091",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 50.049,
          "maximum": 2447.7861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2080.6182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 6MMX10CM M00",
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        {
          "code": "3550094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2529,
          "minimum": 864.5762,
          "maximum": 14053.2031,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1560.001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-ANNULOTOMY 675.405S",
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        {
          "code": "3550111",
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1656.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-SHIM SS 6133.0326S",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.914S",
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        {
          "code": "3550136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 551.6512,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CT 3.5M 6149.9135",
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        {
          "code": "3550137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 3153.6431,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 611.9102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIABETIC FOOT CARE 0811748",
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        {
          "code": "3550156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 159.654,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 135.7059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 71MM 705506",
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        {
          "code": "3550158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 331.9917,
          "maximum": 887.5311,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 754.4014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT RSZ4001S",
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        {
          "code": "3550168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 676.8924,
          "maximum": 2744.9096,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW 1020-00-000",
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        {
          "code": "3550179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 175.3767,
          "maximum": 780.2083,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-C001",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 482.0295,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22GX9CM",
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        {
          "code": "3550200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 138.7971,
          "maximum": 10649.315,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 250.4391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.8X122 A-3738",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 789.366,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIMED RX COUDE 1314ANS",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 244.7752,
          "maximum": 12179.7022,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CERV MOBI-C 13X17 MB3375",
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        {
          "code": "3550228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1119.9854,
          "maximum": 15894.2814,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 13510.1392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPAR 14MM 0024-LDR",
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        {
          "code": "3550229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 12179.7022,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1242.3258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYGEN VOCSN PRT-00930",
      "code_information": [
        {
          "code": "3550231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 134.3529,
          "maximum": 3864.895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 242.4201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE 2.5MM 694",
      "code_information": [
        {
          "code": "3550236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5953,
          "minimum": 2035.1215,
          "maximum": 4320.0921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3672.0783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-INSERTER",
      "code_information": [
        {
          "code": "3550237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1866.2716,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-T 601.800",
      "code_information": [
        {
          "code": "3550239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3487,
          "minimum": 933.1358,
          "maximum": 2530.5159,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2150.9385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPANNER-WRENCH 687.509",
      "code_information": [
        {
          "code": "3550240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INSERTER 694.004",
      "code_information": [
        {
          "code": "3550241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4175,
          "minimum": 1427.2858,
          "maximum": 3029.7975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2575.3279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-INSERTER 694.005",
      "code_information": [
        {
          "code": "3550242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 3070.4367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2609.8712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-CALIBER GRAPHIC 994.001",
      "code_information": [
        {
          "code": "3550244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14166,
          "minimum": 4842.8576,
          "maximum": 22391.3665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8738.2263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARGYLE SHUNT 8888577775",
      "code_information": [
        {
          "code": "3550249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 142.5576,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.2244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND A31216",
      "code_information": [
        {
          "code": "3550250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 93.4248,
          "maximum": 361.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 307.1888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-MEPITEL 6.8X10",
      "code_information": [
        {
          "code": "3550253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 186.8496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.8174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 12FR 1.0CM",
      "code_information": [
        {
          "code": "3550256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 3921.0611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 592.788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-I/A CAPSULGUARD",
      "code_information": [
        {
          "code": "3550264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 164.6976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE RT SM 70831",
      "code_information": [
        {
          "code": "3550272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 338,
          "minimum": 115.5503,
          "maximum": 245.2866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 208.4936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE LT SM 70831",
      "code_information": [
        {
          "code": "3550273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 121.0202,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 218.3631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-OSTEOFUZE OF-BMA-11",
      "code_information": [
        {
          "code": "3550274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8800,
          "minimum": 483.807,
          "maximum": 6386.16,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5428.236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET REUSE",
      "code_information": [
        {
          "code": "3550275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 870,
          "minimum": 80.6345,
          "maximum": 631.359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 536.6551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-HEMOSTATIC POWDER 1978",
      "code_information": [
        {
          "code": "3550278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 10602.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 456.4653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R002",
      "code_information": [
        {
          "code": "3550306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1593.9275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TROCAR THORACIC 24FR SWD",
      "code_information": [
        {
          "code": "3550314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 110.7642,
          "maximum": 477.6899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.8578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-INSPIRA BREAST SRM",
      "code_information": [
        {
          "code": "3550331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4485,
          "minimum": 232.4498,
          "maximum": 3254.7645,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2766.5498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DEFENDO Y-OPSY 100303",
      "code_information": [
        {
          "code": "3550394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 640.0711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.8992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PUSHLOCK 2.9MM",
      "code_information": [
        {
          "code": "3550395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1151,
          "minimum": 393.4865,
          "maximum": 835.2807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 709.9886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM",
      "code_information": [
        {
          "code": "3550396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 837.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH 8MM 100/897/080",
      "code_information": [
        {
          "code": "3550399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 878,
          "minimum": 75.6296,
          "maximum": 637.1646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 541.5899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER 8MM 100/890/080",
      "code_information": [
        {
          "code": "3550400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.8909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 18FR 897518",
      "code_information": [
        {
          "code": "3550406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 195,
          "minimum": 66.6636,
          "maximum": 141.5115,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.2848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR 897516",
      "code_information": [
        {
          "code": "3550407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 195,
          "minimum": 66.6636,
          "maximum": 564.4415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.2848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-TRIPLE NEEDLE INS-5300",
      "code_information": [
        {
          "code": "3550411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4172,
          "minimum": 1426.2602,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2573.4773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPIN W/ADAPTER INS-5910",
      "code_information": [
        {
          "code": "3550414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4906,
          "minimum": 207.4253,
          "maximum": 3560.2842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3026.2416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J556G",
      "code_information": [
        {
          "code": "3550419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 132.8031,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.8826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0 770G",
      "code_information": [
        {
          "code": "3550420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 52.8295,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8695G",
      "code_information": [
        {
          "code": "3550421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 6549.7458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-REDDIE KNEE XL 08154723",
      "code_information": [
        {
          "code": "3550426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 437,
          "minimum": 148.4787,
          "maximum": 317.1309,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 269.5613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-BACK ROLYANFIT MESH",
      "code_information": [
        {
          "code": "3550427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 46414.3304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 164.6976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-2.3MM PED SCREW 4008-00",
      "code_information": [
        {
          "code": "3550429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 811.906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 676.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING RS5200",
      "code_information": [
        {
          "code": "3550447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5472,
          "minimum": 325.3185,
          "maximum": 3971.0304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3375.3758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-FIXATION LG FP9000L",
      "code_information": [
        {
          "code": "3550448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 36889.4496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 360.8543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-PRIME 286750200S",
      "code_information": [
        {
          "code": "3550473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 9520.9881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1656.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-MMG 2862-02-108",
      "code_information": [
        {
          "code": "3550480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1175,
          "minimum": 401.6912,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 724.7929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 03.010.060",
      "code_information": [
        {
          "code": "3550483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1814,
          "minimum": 620.1429,
          "maximum": 7248.7635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1118.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-120",
      "code_information": [
        {
          "code": "3550487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 344.2579,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 621.1629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-120LP",
      "code_information": [
        {
          "code": "3550488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 959,
          "minimum": 327.8484,
          "maximum": 721.8178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 591.5544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MACY BEDSIDE DELIVERY M",
      "code_information": [
        {
          "code": "3550498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 932,
          "minimum": 88.4199,
          "maximum": 676.3524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 574.8995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PRESSURE OPAQUE 50P148",
      "code_information": [
        {
          "code": "3550499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 369.8065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH,MALE EXTERNAL",
      "code_information": [
        {
          "code": "3550511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH PEDIATRIC",
      "code_information": [
        {
          "code": "3550515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.2741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO CF DEL FGS-0635",
      "code_information": [
        {
          "code": "3550530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2212,
          "minimum": 756.2051,
          "maximum": 7374.4421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1364.4611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM ST 6149.1036S",
      "code_information": [
        {
          "code": "3550541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 611.9102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF MED MDS601MD",
      "code_information": [
        {
          "code": "3550553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 105.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.0594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF XL MDS601BD",
      "code_information": [
        {
          "code": "3550555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.2195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT MED MDS620",
      "code_information": [
        {
          "code": "3550556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 257,
          "minimum": 87.8593,
          "maximum": 186.5049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.5292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT LRG MDS620L",
      "code_information": [
        {
          "code": "3550557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 277,
          "minimum": 94.6966,
          "maximum": 201.0189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.8661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH MED MDS630MD",
      "code_information": [
        {
          "code": "3550558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 351,
          "minimum": 119.9946,
          "maximum": 254.7207,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 216.5126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH LRG MDS630LD",
      "code_information": [
        {
          "code": "3550559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH X-LG MDS630BD",
      "code_information": [
        {
          "code": "3550560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 383,
          "minimum": 130.9342,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 236.2516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT 10° TIP MLD-0068",
      "code_information": [
        {
          "code": "3550592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 662.3151,
          "maximum": 2289.5835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1946.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.5X350MM PK6 MLD-0301",
      "code_information": [
        {
          "code": "3550593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 2744.9096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 734.6624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-8/13/18MM MLD-0441S",
      "code_information": [
        {
          "code": "3550594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1041.5753,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3044.7469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIM-SPIKE BLUNT MLD-0513",
      "code_information": [
        {
          "code": "3550595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1873,
          "minimum": 640.3129,
          "maximum": 1359.2361,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1155.3507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- DILATOR MLD-0345",
      "code_information": [
        {
          "code": "3550596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 9520.9881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 734.6624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-THORACIC TGMR312610",
      "code_information": [
        {
          "code": "3550613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84847,
          "minimum": 3513.4398,
          "maximum": 61573.4679,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52337.4477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X12MM 03.501.762",
      "code_information": [
        {
          "code": "3550619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2487,
          "minimum": 207.4253,
          "maximum": 1804.8159,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1534.0935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX16CM",
      "code_information": [
        {
          "code": "3550630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 353.4522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX16CM",
      "code_information": [
        {
          "code": "3550631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICAL SCREW 3603-00-TE",
      "code_information": [
        {
          "code": "3550634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 676.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PEDIATRIC YG-232T",
      "code_information": [
        {
          "code": "3550638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.2872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC 153509",
      "code_information": [
        {
          "code": "3550645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3ML 165810",
      "code_information": [
        {
          "code": "3550646",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-MARKING ROBOTIP INFARED",
      "code_information": [
        {
          "code": "3550649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 473.2411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE F/MRI SQK65VS",
      "code_information": [
        {
          "code": "3550657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 164.7339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.0238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE,FLEX FLEX-200-QFT",
      "code_information": [
        {
          "code": "3550658",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 769.6424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE 24F 5CC 0",
      "code_information": [
        {
          "code": "3550665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 170,
          "minimum": 58.117,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.8636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ASSEMBLY DISP 83030-1",
      "code_information": [
        {
          "code": "3550668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1576,
          "minimum": 538.779,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 972.1477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY 18G ANG 221251",
      "code_information": [
        {
          "code": "3550683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 149,
          "minimum": 50.9379,
          "maximum": 438.2068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.9099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VS-1 5FR 80CM BEACON TIP",
      "code_information": [
        {
          "code": "3550691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 211.5778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-VASC 14X7MM SBT1402D",
      "code_information": [
        {
          "code": "3550693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 346.4503,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL DETACHMENT RH1",
      "code_information": [
        {
          "code": "3550699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 985.7183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE D9212",
      "code_information": [
        {
          "code": "3550703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1077,
          "minimum": 368.1885,
          "maximum": 4252.4967,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 664.3421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SMARTRELEASE ONYX 83030-",
      "code_information": [
        {
          "code": "3550710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1969,
          "minimum": 497.7095,
          "maximum": 1428.9033,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1214.5678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM 2.3MM 2862-02-201",
      "code_information": [
        {
          "code": "3550713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3171,
          "minimum": 1084.0535,
          "maximum": 7919.9762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1956.0155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE ULTRASOUND 8’ CVC6",
      "code_information": [
        {
          "code": "3550720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BONE HARVEST 03.404.000S",
      "code_information": [
        {
          "code": "3550737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12726,
          "minimum": 870.8526,
          "maximum": 9235.2582,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7849.9695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MENISCAL ROOT 71935068",
      "code_information": [
        {
          "code": "3550740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5252,
          "minimum": 1795.4742,
          "maximum": 3811.3764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3239.6699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-REAMER",
      "code_information": [
        {
          "code": "3550752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3893,
          "minimum": 60.6149,
          "maximum": 2825.1501,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2401.3776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXY ADULT ETCO2 OM-2125-8",
      "code_information": [
        {
          "code": "3550753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.2361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONET 188MM 1563-00",
      "code_information": [
        {
          "code": "3550760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 4252.4967,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1242.3258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT INTERSTIM 3560022",
      "code_information": [
        {
          "code": "3550762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1631,
          "minimum": 557.5816,
          "maximum": 1183.6167,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1006.0742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 3MM BIT DK-300",
      "code_information": [
        {
          "code": "3550765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2326,
          "minimum": 795.1777,
          "maximum": 4216.3502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1434.7815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DECOMPRESSION ZZ-0056",
      "code_information": [
        {
          "code": "3550777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,LASER TRACH",
      "code_information": [
        {
          "code": "3550778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 675.725S",
      "code_information": [
        {
          "code": "3550783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8123,
          "minimum": 2776.9683,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5010.6319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP THR 1.35M",
      "code_information": [
        {
          "code": "3550793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 48.3807,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.8198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0 8762H",
      "code_information": [
        {
          "code": "3550794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (15) 8800966",
      "code_information": [
        {
          "code": "3550803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 187.4057,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (5) 8801002",
      "code_information": [
        {
          "code": "3550804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 337,
          "minimum": 115.2085,
          "maximum": 884.7551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 207.8768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 4.6X220 P99-110-4622",
      "code_information": [
        {
          "code": "3550805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1591,
          "minimum": 543.907,
          "maximum": 10633.7442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 981.4004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM ADJ 2862-02-200",
      "code_information": [
        {
          "code": "3550815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3171,
          "minimum": 818.5792,
          "maximum": 2301.1947,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1956.0155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.1X50 M-R 01-7141",
      "code_information": [
        {
          "code": "3550816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1472,
          "minimum": 503.2251,
          "maximum": 4615.0739,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 907.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL EMBOLIZATION PODH1",
      "code_information": [
        {
          "code": "3550822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 15669.2297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 985.7183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 AO A-8004.03",
      "code_information": [
        {
          "code": "3550830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1879,
          "minimum": 642.3641,
          "maximum": 4742.9769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1159.0518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 16FR PEDS 8016",
      "code_information": [
        {
          "code": "3550842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 2791.622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.45MM SM 45303145",
      "code_information": [
        {
          "code": "3550850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 207.4253,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAGE-12MM/8° 50/18 LUI81249",
      "code_information": [
        {
          "code": "3550854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 19856,
          "minimum": 870.8526,
          "maximum": 14409.4992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 12248.0743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-CUSTOM MED PK623984",
      "code_information": [
        {
          "code": "3550856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52648,
          "minimum": 667.8761,
          "maximum": 38206.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32475.6556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BAL RX DC-RYxxxxxx",
      "code_information": [
        {
          "code": "3550857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 2455.1815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-R2P MISAGO SXRxxxxxx",
      "code_information": [
        {
          "code": "3550858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4415,
          "minimum": 1028.785,
          "maximum": 3203.9655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2723.3707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-METACROSS BD-xxxxxxxx",
      "code_information": [
        {
          "code": "3550859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1850,
          "minimum": 632.45,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1141.1633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT F/2.16MM 3560030",
      "code_information": [
        {
          "code": "3550864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 14240.6088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-INTERPULSE",
      "code_information": [
        {
          "code": "3550869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.6952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-SKULL MOUNT 9735300",
      "code_information": [
        {
          "code": "3550873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1643,
          "minimum": 561.684,
          "maximum": 1192.3251,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1013.4763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16FR A3",
      "code_information": [
        {
          "code": "3550876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 437,
          "minimum": 149.3949,
          "maximum": 37124.1238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 269.5613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PERFORATED FUNCTIONAL 0",
      "code_information": [
        {
          "code": "3550898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 177.6514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-HI-SPEED 4X11 1884068HS",
      "code_information": [
        {
          "code": "3550911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2381,
          "minimum": 813.9802,
          "maximum": 1727.8917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1468.7079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PROLAPSE HEM3335",
      "code_information": [
        {
          "code": "3550912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2317,
          "minimum": 792.1009,
          "maximum": 3664.1429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1429.2299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM XT SIGTRSB60AXT",
      "code_information": [
        {
          "code": "3550915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3076,
          "minimum": 1051.5763,
          "maximum": 2232.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1897.4152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM MT SIGTRSB60AMT",
      "code_information": [
        {
          "code": "3550916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 865.2916,
          "maximum": 1851.2607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1573.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3551250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 38.3709,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.1626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PRECISE SKIN      DS-5",
      "code_information": [
        {
          "code": "3552655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 68.4003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT  STR 35R",
      "code_information": [
        {
          "code": "3552730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 36.1465,
          "maximum": 89.2611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3552731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.0949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3552732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXW35",
      "code_information": [
        {
          "code": "3552737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 333.1039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.5078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKING-COMPRESSION CUSTOM",
      "code_information": [
        {
          "code": "3553701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 5096.1004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 369.4902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-BONE",
      "code_information": [
        {
          "code": "3554025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9164,
          "minimum": 74.5174,
          "maximum": 6650.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5652.7676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CLAVICAL ADULT ALL 3001s",
      "code_information": [
        {
          "code": "3554085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 192.9667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.6572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "3554974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 231.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.8909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3554981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 142.5576,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.2244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-1/2\\\"X2\\\" SMALL    1955",
      "code_information": [
        {
          "code": "3555059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 440.4312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.6621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2\\\"X14\\\" LARGE     1951",
      "code_information": [
        {
          "code": "3555109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 270.757,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 488.5412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2 X 3 MEDIUM     1953",
      "code_information": [
        {
          "code": "3555158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 489,
          "minimum": 65.0637,
          "maximum": 354.8673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 301.6372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP MED  202549",
      "code_information": [
        {
          "code": "3555307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 84.9069,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP LG   202636",
      "code_information": [
        {
          "code": "3555315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 274.1573,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORIE-XLGE 202612&201352",
      "code_information": [
        {
          "code": "3555323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 493,
          "minimum": 33.366,
          "maximum": 357.7701,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.1046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       G121H",
      "code_information": [
        {
          "code": "3555374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0 FS-2   636H",
      "code_information": [
        {
          "code": "3555390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 23.9123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.1684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-DEXON           7618-41",
      "code_information": [
        {
          "code": "3556875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 43,
          "minimum": 14.7002,
          "maximum": 31.2051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 26.5243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0   1663H",
      "code_information": [
        {
          "code": "3557098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 41,
          "minimum": 7.7854,
          "maximum": 29.7537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 25.2906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3557628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 36.1465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.1684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 6-0 P1       697G",
      "code_information": [
        {
          "code": "3557898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.0949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        698H",
      "code_information": [
        {
          "code": "3557956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        990H",
      "code_information": [
        {
          "code": "3558678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 8.8976,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.0487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685G",
      "code_information": [
        {
          "code": "3558679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 16,
          "minimum": 5.4698,
          "maximum": 51.7173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 9.8695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1653-G",
      "code_information": [
        {
          "code": "3558947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 27.2489,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1663-H",
      "code_information": [
        {
          "code": "3558970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 49,
          "minimum": 16.7514,
          "maximum": 40.5953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 30.2254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0       1667G",
      "code_information": [
        {
          "code": "3558978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 3-0       1669H",
      "code_information": [
        {
          "code": "3558982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 220.7717,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE P99-930-2108",
      "code_information": [
        {
          "code": "3559011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3368,
          "minimum": 900.3259,
          "maximum": 2444.1576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2077.534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       G695G",
      "code_information": [
        {
          "code": "3559030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1696-G",
      "code_information": [
        {
          "code": "3559036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON           1698G",
      "code_information": [
        {
          "code": "3559069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM MT SIGTRSB45AMT",
      "code_information": [
        {
          "code": "3559071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2310,
          "minimum": 789.7078,
          "maximum": 2108.1751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.9119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-LONG 4.2MM 703545",
      "code_information": [
        {
          "code": "3559085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3448,
          "minimum": 870.8526,
          "maximum": 2502.2136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2126.8816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-5X100MM FIX UNVCA5STF",
      "code_information": [
        {
          "code": "3559095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 156,
          "minimum": 53.3309,
          "maximum": 247.4645,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.2278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 15MM ONB15STF",
      "code_information": [
        {
          "code": "3559096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 274.496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 5MM ONB5STF",
      "code_information": [
        {
          "code": "3559097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 286,
          "minimum": 97.7733,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 176.4177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3559115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 21028.3654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 12FR 0200-12L",
      "code_information": [
        {
          "code": "3559117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 473.141,
          "maximum": 1004.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.7135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM CDH29P",
      "code_information": [
        {
          "code": "3559120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2660,
          "minimum": 497.7095,
          "maximum": 1930.362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1640.8077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3559142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2143,
          "minimum": 142.9177,
          "maximum": 1555.1751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1321.8988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15MM XTHICK SIG60AXT",
      "code_information": [
        {
          "code": "3559150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1896,
          "minimum": 648.1758,
          "maximum": 3212.5897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1169.5381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1065832",
      "code_information": [
        {
          "code": "3559158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 351.4552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.9751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIAMONDTOUCH IN9152",
      "code_information": [
        {
          "code": "3559159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 632,
          "minimum": 216.0586,
          "maximum": 1504.2505,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 389.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN GUARD",
      "code_information": [
        {
          "code": "3559160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1668.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLLEVE-SPIN GUARD",
      "code_information": [
        {
          "code": "3559161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1702,
          "minimum": 581.854,
          "maximum": 1235.1414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1049.8702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYDROGEL EEG",
      "code_information": [
        {
          "code": "3559175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.9265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J493H",
      "code_information": [
        {
          "code": "3559178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0 1635G",
      "code_information": [
        {
          "code": "3559179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 100.6541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J670G",
      "code_information": [
        {
          "code": "3559180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.6489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP497G",
      "code_information": [
        {
          "code": "3559181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 185,
          "minimum": 63.245,
          "maximum": 134.2545,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.1163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-12MM 10*/MD 08.815.242S",
      "code_information": [
        {
          "code": "3559197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 23165,
          "minimum": 1787.3054,
          "maximum": 16810.8405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 14289.2144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW-ACC BONCH AF541",
      "code_information": [
        {
          "code": "3559228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW,STD BLUE AF541 73-112096",
      "code_information": [
        {
          "code": "3559229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 10665.4419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM/MED/LG",
      "code_information": [
        {
          "code": "3559240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 189,
          "minimum": 64.6125,
          "maximum": 105398.1891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 116.5837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.2MM XS 45303125",
      "code_information": [
        {
          "code": "3559246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD 4033A",
      "code_information": [
        {
          "code": "3559253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X40MM 7005-3340",
      "code_information": [
        {
          "code": "3559254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 433.2429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X60MM 7005-3360",
      "code_information": [
        {
          "code": "3559255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 2859.4662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 10G 0306-530-000",
      "code_information": [
        {
          "code": "3559260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 642,
          "minimum": 219.4772,
          "maximum": 465.8994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 396.0145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ TRANS 0909-400-500",
      "code_information": [
        {
          "code": "3559261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 700,
          "minimum": 239.3054,
          "maximum": 1316.2887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.7915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 1025-011-500",
      "code_information": [
        {
          "code": "3559262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2367,
          "minimum": 335.8844,
          "maximum": 1717.7319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1460.0721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CEMENT 0306-410-000",
      "code_information": [
        {
          "code": "3559263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 604,
          "minimum": 206.4864,
          "maximum": 4504.9661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 372.5744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INDIGO SEP12",
      "code_information": [
        {
          "code": "3559264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8101,
          "minimum": 1811.2177,
          "maximum": 5878.8957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4997.0613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURRETTE-10G 0306-621-000",
      "code_information": [
        {
          "code": "3559265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3257,
          "minimum": 497.7095,
          "maximum": 2363.6049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2009.0642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FLEX CUFFED",
      "code_information": [
        {
          "code": "3559271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 750,
          "minimum": 256.3986,
          "maximum": 2534.7038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 462.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-FLEXIBLE 2.9MM 682.622",
      "code_information": [
        {
          "code": "3559276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1242.3258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2516H",
      "code_information": [
        {
          "code": "3559281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.1519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COILED 60\\\" CT 100113",
      "code_information": [
        {
          "code": "3559287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 2641.475,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-GPS 3.5MM 6143.2572",
      "code_information": [
        {
          "code": "3559291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 3212.5897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4.2X360/SM 1320-3642S",
      "code_information": [
        {
          "code": "3559293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 959,
          "minimum": 327.8484,
          "maximum": 3425.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 591.5544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383593",
      "code_information": [
        {
          "code": "3559297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON BLK 4-0   1854G",
      "code_information": [
        {
          "code": "3559366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 59.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 PC-1  1855G",
      "code_information": [
        {
          "code": "3559390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 646.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER 4MM SB4000SA",
      "code_information": [
        {
          "code": "3559391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1162,
          "minimum": 99.5419,
          "maximum": 843.2634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 716.7739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING 19F L",
      "code_information": [
        {
          "code": "3559394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 522.1779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCESS 8MM",
      "code_information": [
        {
          "code": "3559395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 939,
          "minimum": 50.049,
          "maximum": 681.4323,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 579.2175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3559401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1438,
          "minimum": 491.6017,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 887.0231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FIBERLASE CO2",
      "code_information": [
        {
          "code": "3559407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 5441.9946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3131.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER ELEVATE 8340155",
      "code_information": [
        {
          "code": "3559412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4241.3747,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0/PC-3  1865G",
      "code_information": [
        {
          "code": "3559425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 780.2083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MIC J FEDDING 8200",
      "code_information": [
        {
          "code": "3559430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 473.141,
          "maximum": 2490.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.7135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT SINGLE 5' RT219",
      "code_information": [
        {
          "code": "3559433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 377,
          "minimum": 128.8831,
          "maximum": 273.5889,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.5506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT DUAL HTDRT380",
      "code_information": [
        {
          "code": "3559434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 386,
          "minimum": 131.9598,
          "maximum": 452.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 238.1022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 EPM8706",
      "code_information": [
        {
          "code": "3559435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 814,
          "minimum": 278.278,
          "maximum": 590.7198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 502.1118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 2X315MM 703561",
      "code_information": [
        {
          "code": "3559445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 170.2487,
          "maximum": 6317.296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 307.1888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VIZISNOT2 19G",
      "code_information": [
        {
          "code": "3559447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2067,
          "minimum": 212.4302,
          "maximum": 1500.0219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1275.0186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIP 8.5X110 72200436",
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        {
          "code": "3559448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 10602.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.100",
      "code_information": [
        {
          "code": "3559462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 751.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 K-WIRE",
      "code_information": [
        {
          "code": "3559463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 613.1439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 22X10MM 03.501.760",
      "code_information": [
        {
          "code": "3559485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2487,
          "minimum": 850.2179,
          "maximum": 1804.8159,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1534.0935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2590S",
      "code_information": [
        {
          "code": "3559495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 284,
          "minimum": 97.0896,
          "maximum": 206.0988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2591S",
      "code_information": [
        {
          "code": "3559496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 284,
          "minimum": 97.0896,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM GPS 6143.2580S",
      "code_information": [
        {
          "code": "3559499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1138.6959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM GPS 6143.2582S",
      "code_information": [
        {
          "code": "3559500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1138.6959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM GPS 6143.2584S",
      "code_information": [
        {
          "code": "3559501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1138.6959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 8FR G00980",
      "code_information": [
        {
          "code": "3559527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 7425.6033,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-6MM BALT 110135",
      "code_information": [
        {
          "code": "3559542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 710,
          "minimum": 242.7241,
          "maximum": 577.7879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 437.9599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-OVASSAPIAN 85MM BD6075",
      "code_information": [
        {
          "code": "3559545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 1653.8414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/55 STANDARD 7607",
      "code_information": [
        {
          "code": "3559546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2974,
          "minimum": 721.8178,
          "maximum": 2158.2318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1834.497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8013090",
      "code_information": [
        {
          "code": "3559559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5281.8378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8340050",
      "code_information": [
        {
          "code": "3559560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9498,
          "minimum": 3247.0324,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5858.7938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y3/8X3/16X3/16 10518",
      "code_information": [
        {
          "code": "3559582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 6173.2661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CABLE 323.1090",
      "code_information": [
        {
          "code": "3559590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1886,
          "minimum": 644.7571,
          "maximum": 1368.6702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1163.3697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BRAD POINT 4MM 323.010",
      "code_information": [
        {
          "code": "3559591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2034,
          "minimum": 695.3531,
          "maximum": 9633.8764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1254.6627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRIPLE LUMEN 5.5FR",
      "code_information": [
        {
          "code": "3559593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1240,
          "minimum": 423.9124,
          "maximum": 899.868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 764.8878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL LUMEN 4FR",
      "code_information": [
        {
          "code": "3559594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1190,
          "minimum": 406.8192,
          "maximum": 34190.6963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 734.0455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 4.5X15 9009-2001",
      "code_information": [
        {
          "code": "3559598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3360,
          "minimum": 1148.6659,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2072.5992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM XT SIGTRSB45AXT",
      "code_information": [
        {
          "code": "3559607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2514,
          "minimum": 859.4483,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1550.7483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/F P01-900-1902",
      "code_information": [
        {
          "code": "3559612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1668.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/M P01-900-1903",
      "code_information": [
        {
          "code": "3559613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 3857.6657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1668.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEE-UTILIZATION PER CASE",
      "code_information": [
        {
          "code": "3559626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4344,
          "minimum": 1485.061,
          "maximum": 3152.4408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2679.5747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.0MM 705360",
      "code_information": [
        {
          "code": "3559634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1250,
          "minimum": 427.3311,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 771.0562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SENSOR SPO2 1822A-25",
      "code_information": [
        {
          "code": "3559649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 687.8957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASO 12FR",
      "code_information": [
        {
          "code": "3559651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.7794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A435",
      "code_information": [
        {
          "code": "3559659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 393,
          "minimum": 134.3529,
          "maximum": 558.8805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 242.4201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #4 051114-10",
      "code_information": [
        {
          "code": "3559671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 82.7313,
          "maximum": 189.6301,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.2765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC",
      "code_information": [
        {
          "code": "3559672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 341,
          "minimum": 116.5759,
          "maximum": 1016.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 210.3441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 3.5X65",
      "code_information": [
        {
          "code": "3559673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1828,
          "minimum": 624.929,
          "maximum": 1326.5796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1127.5927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURETTE-0* TIP TDC005",
      "code_information": [
        {
          "code": "3559688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1582.7517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1345.3389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-0* TIP NAVIGATION",
      "code_information": [
        {
          "code": "3559690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1980,
          "minimum": 676.8924,
          "maximum": 5458.1215,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1221.3531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON SILK    C-021-",
      "code_information": [
        {
          "code": "3560079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 7.7854,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.6762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PS-2/4-0   J496G",
      "code_information": [
        {
          "code": "3560474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 7.7854,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J492G",
      "code_information": [
        {
          "code": "3560778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J493G",
      "code_information": [
        {
          "code": "3560802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.4128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J494G",
      "code_information": [
        {
          "code": "3560836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 4-0  J-496-H",
      "code_information": [
        {
          "code": "3560879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 42.8163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-497-G",
      "code_information": [
        {
          "code": "3560893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 95.6492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-774-D",
      "code_information": [
        {
          "code": "3561255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 7.7854,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.0973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J762D",
      "code_information": [
        {
          "code": "3561415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 7.7854,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0        699H",
      "code_information": [
        {
          "code": "3561696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 7.7854,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y496G",
      "code_information": [
        {
          "code": "3562112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 7.7854,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y494G",
      "code_information": [
        {
          "code": "3562131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS-2    1666",
      "code_information": [
        {
          "code": "3562141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 40,
          "minimum": 13.6746,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 24.6738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8619G",
      "code_information": [
        {
          "code": "3562217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 7.7854,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8699G",
      "code_information": [
        {
          "code": "3562235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 7.7854,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.0487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIVERSAL*****",
      "code_information": [
        {
          "code": "3566070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 92.8896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-EAR DAVOL 3 OZ 529****",
      "code_information": [
        {
          "code": "3566353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 112.3322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.0759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CT FAST LOAD DUAL",
      "code_information": [
        {
          "code": "3566355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 66.732,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.6027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-PACK DUAL EMPOWERCTA",
      "code_information": [
        {
          "code": "3566380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 3586.845,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CRANIAL ACCESS  INSHITH",
      "code_information": [
        {
          "code": "3566755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2554,
          "minimum": 546.0902,
          "maximum": 1853.4378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1575.4221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MULTI PODUS 9274-56XX",
      "code_information": [
        {
          "code": "3566785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 982,
          "minimum": 74.5174,
          "maximum": 712.6374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 605.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NURSING SUPPLEMENTAL",
      "code_information": [
        {
          "code": "3566790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.6572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FECAL MANAGEMENT",
      "code_information": [
        {
          "code": "3566823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1240,
          "minimum": 40.5953,
          "maximum": 899.868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 764.8878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-REPLACEMENT FECAL MGMT",
      "code_information": [
        {
          "code": "3566824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 512.1681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3567605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 921,
          "minimum": 104.5468,
          "maximum": 668.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.1142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "THERMOSET-INJECTATE    4142403",
      "code_information": [
        {
          "code": "3568123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 3118.0527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 8.0MM",
      "code_information": [
        {
          "code": "3568561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 274.496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 6.0MM",
      "code_information": [
        {
          "code": "3568562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 450,
          "minimum": 153.8392,
          "maximum": 326.565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 277.5802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3568563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 274.496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 508,
          "minimum": 173.6673,
          "maximum": 368.6556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 313.3573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU UNCUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 99.5419,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4259105",
      "code_information": [
        {
          "code": "3568757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 380,
          "minimum": 84.5272,
          "maximum": 275.766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 234.4011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-NEONATAL   42634-05",
      "code_information": [
        {
          "code": "3568760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 121.7859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXISENSOR-PEDIATRIC D20",
      "code_information": [
        {
          "code": "3568762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 630.0613,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.0891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565200",
      "code_information": [
        {
          "code": "3569240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 387.3329,
          "maximum": 822.2181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 698.8854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565150",
      "code_information": [
        {
          "code": "3569242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 203.5326,
          "maximum": 822.2181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 698.8854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16 FR",
      "code_information": [
        {
          "code": "3569250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 366,
          "minimum": 125.1225,
          "maximum": 265.6062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.7653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18 FR",
      "code_information": [
        {
          "code": "3569252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 366,
          "minimum": 11.122,
          "maximum": 265.6062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.7653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH URETHRAL BARD 772415",
      "code_information": [
        {
          "code": "3569258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 20,
          "minimum": 6.8373,
          "maximum": 608.9295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 12.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-ESOPH TRACH     5-18541",
      "code_information": [
        {
          "code": "3569601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1095,
          "minimum": 40.5953,
          "maximum": 794.6415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 675.4453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY CATH/DRN BAG 6176LL",
      "code_information": [
        {
          "code": "3569779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR   6146LL",
      "code_information": [
        {
          "code": "3569805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/ BAG 18FR  6148LL",
      "code_information": [
        {
          "code": "3569853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 77.6499,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.0024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG LTX 16F 6165L",
      "code_information": [
        {
          "code": "3569870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LOOP CCL DYNJ50892",
      "code_information": [
        {
          "code": "3570230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.5209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMBAR PUNCTURE ADT 4301C",
      "code_information": [
        {
          "code": "3570322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 69.5125,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMB PUNC PED   4304C****",
      "code_information": [
        {
          "code": "3570330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 310.3038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR PROC OP DYNJ31942F",
      "code_information": [
        {
          "code": "3570410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 65.0637,
          "maximum": 404.9406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.1995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PARA/PUD PHARMASEAL 4540A",
      "code_information": [
        {
          "code": "3570603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 540.5292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 6.0F",
      "code_information": [
        {
          "code": "3570605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 705.3804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 599.5733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 8.3F",
      "code_information": [
        {
          "code": "3570610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1211,
          "minimum": 382.0407,
          "maximum": 878.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 746.9993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SINGLE TAP BLOCK SPEC015",
      "code_information": [
        {
          "code": "3570640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 687,
          "minimum": 234.8612,
          "maximum": 498.5559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 423.7725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-NICU UMBILICAL CATH",
      "code_information": [
        {
          "code": "3570745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 543,
          "minimum": 185.6326,
          "maximum": 394.0551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.9468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-THORACENTESIS CURITY 5014*",
      "code_information": [
        {
          "code": "3571304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 404.8408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.9503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 16FR 0100-16LV",
      "code_information": [
        {
          "code": "3571985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 87.8638,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 233.1674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING W/ST 10F 43\\\"",
      "code_information": [
        {
          "code": "3571990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 177.952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.4615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 8.0     86552",
      "code_information": [
        {
          "code": "3572176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 413.1823,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.3904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 6LPC",
      "code_information": [
        {
          "code": "3572189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 743,
          "minimum": 201.8643,
          "maximum": 539.1951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 458.3158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 6CFS",
      "code_information": [
        {
          "code": "3572191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 281.9427,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 6MM",
      "code_information": [
        {
          "code": "3572195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 507,
          "minimum": 173.3255,
          "maximum": 559.9927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.7404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRP MIC-KEY 14FR 1.5CM",
      "code_information": [
        {
          "code": "3572305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 344.2579,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 621.1629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 35FR     125135",
      "code_information": [
        {
          "code": "3572307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 428.0904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 39FR     125139",
      "code_information": [
        {
          "code": "3572309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 428.0904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 41FR     125141",
      "code_information": [
        {
          "code": "3572311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 428.0904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 37FR LFT 125037",
      "code_information": [
        {
          "code": "3572315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 619,
          "minimum": 211.6143,
          "maximum": 1485.8992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 381.8271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BLAKEMORE 20 FR      9210",
      "code_information": [
        {
          "code": "3572344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2672,
          "minimum": 40.5953,
          "maximum": 1939.0704,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1648.2098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 5F 20\\\"     461412",
      "code_information": [
        {
          "code": "3572425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 6.5F 36\\\"   461438",
      "code_information": [
        {
          "code": "3572430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 77.2979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.0949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASOGASTRIC 8FR",
      "code_information": [
        {
          "code": "3572485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 131.7957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 18FR 20CC",
      "code_information": [
        {
          "code": "3572530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 237,
          "minimum": 48.3807,
          "maximum": 171.9909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 146.1923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.5       86215",
      "code_information": [
        {
          "code": "3572860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.0       8621",
      "code_information": [
        {
          "code": "3572863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.0       86212",
      "code_information": [
        {
          "code": "3572865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.5       86213",
      "code_information": [
        {
          "code": "3572866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 8.0C      86216",
      "code_information": [
        {
          "code": "3572867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "3573037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "3573039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 393.1627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.2444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM",
      "code_information": [
        {
          "code": "3573355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 436.1094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 8MM",
      "code_information": [
        {
          "code": "3573357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 436.1094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF    SZs  DCTs",
      "code_information": [
        {
          "code": "3573530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 461,
          "minimum": 157.5997,
          "maximum": 334.5477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 284.3655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FENESTRATED SZ 4TO10  CFN",
      "code_information": [
        {
          "code": "3573565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 1622.6998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 211.5778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH #6   518035",
      "code_information": [
        {
          "code": "3573650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 413.1823,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1799.9537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 8FR     8LPC",
      "code_information": [
        {
          "code": "3573714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 743,
          "minimum": 177.952,
          "maximum": 539.1951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 458.3158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,TRAC REINFO 6.0 86548",
      "code_information": [
        {
          "code": "3573730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.3904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 7.0     86550",
      "code_information": [
        {
          "code": "3573735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 237.4547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.3904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEEY PED",
      "code_information": [
        {
          "code": "3573845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 427,
          "minimum": 145.9763,
          "maximum": 324.2063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 263.3928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 583,
          "minimum": 199.3072,
          "maximum": 423.0831,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 359.6206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 520,
          "minimum": 177.7697,
          "maximum": 377.364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 320.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 0.8MM",
      "code_information": [
        {
          "code": "3573906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 501,
          "minimum": 171.2743,
          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.0393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3573910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 435,
          "minimum": 148.7112,
          "maximum": 315.6795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF BLU 10.0MM",
      "code_information": [
        {
          "code": "3573911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 6.0MM",
      "code_information": [
        {
          "code": "3573914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 778.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 6.0MM",
      "code_information": [
        {
          "code": "3573915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1400,
          "minimum": 478.6108,
          "maximum": 1015.98,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 863.583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 8.0MM",
      "code_information": [
        {
          "code": "3573916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 229.6693,
          "maximum": 816.4125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 693.9506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF 7.0MM",
      "code_information": [
        {
          "code": "3573920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 413,
          "minimum": 141.1902,
          "maximum": 373.6992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 254.757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 60A160",
      "code_information": [
        {
          "code": "3573926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 672,
          "minimum": 229.7332,
          "maximum": 487.6704,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 414.5198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 7MM",
      "code_information": [
        {
          "code": "3573937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE XL 7",
      "code_information": [
        {
          "code": "3573950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 40.5953,
          "maximum": 816.4125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 693.9506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNDERPAD-CGLIDE XL 40X80 PK",
      "code_information": [
        {
          "code": "3574527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 69.5125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-D&C COLLECTION 23116",
      "code_information": [
        {
          "code": "3574563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 367.5821,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-MITY-ONE MYSTIC   10058",
      "code_information": [
        {
          "code": "3574642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 661,
          "minimum": 33.9221,
          "maximum": 479.6877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 407.7345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI-REFLUX",
      "code_information": [
        {
          "code": "3574651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 488.8119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING TRACH    PMV007",
      "code_information": [
        {
          "code": "3574654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 879,
          "minimum": 300.4992,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 542.2068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAX-BONE                  W31G",
      "code_information": [
        {
          "code": "3575105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 152.3714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER PK",
      "code_information": [
        {
          "code": "3575110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 230.2254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.0155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER XLPK",
      "code_information": [
        {
          "code": "3575115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 414,
          "minimum": 77.2979,
          "maximum": 300.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 255.3738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-FOAM POSITIONING DISP",
      "code_information": [
        {
          "code": "3575122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 180.1764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MEDTRONIC ATRIAL    6492F",
      "code_information": [
        {
          "code": "3575572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 99.5419,
          "maximum": 235.1268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.8578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK L/XL",
      "code_information": [
        {
          "code": "3575890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 235.8525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 200.4746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-THROMBIDISC TOPICAL HEMO",
      "code_information": [
        {
          "code": "3575891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 230.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD S/M",
      "code_information": [
        {
          "code": "3575892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 301.1655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 255.9907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD L/XL",
      "code_information": [
        {
          "code": "3575893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 518,
          "minimum": 177.086,
          "maximum": 375.9126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.5257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-LEG POSITIONER 111618",
      "code_information": [
        {
          "code": "3575894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 211.5778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK S/M",
      "code_information": [
        {
          "code": "3575895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 30.5855,
          "maximum": 196.6647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRISTLET-PORTHOLE 6600021150",
      "code_information": [
        {
          "code": "3576870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.9265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH 442-2",
      "code_information": [
        {
          "code": "3576880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 41.1514,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EXUDE HYDRO 6X6",
      "code_information": [
        {
          "code": "3580000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.6465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-OPTICELL AG+4X5",
      "code_information": [
        {
          "code": "3580001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 104.5468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.5078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 16FR",
      "code_information": [
        {
          "code": "3580005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST RT XS 8",
      "code_information": [
        {
          "code": "3580008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.1436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LT XS 8",
      "code_information": [
        {
          "code": "3580009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 102.8785,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 EASY CAP II",
      "code_information": [
        {
          "code": "3580015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 171,
          "minimum": 58.4589,
          "maximum": 124.0947,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.4805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 14FR",
      "code_information": [
        {
          "code": "3580016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 145.6982,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-NASAL L/R STANDARD",
      "code_information": [
        {
          "code": "3580017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 262,
          "minimum": 47.2685,
          "maximum": 190.1334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 161.6134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT MED CLOSED",
      "code_information": [
        {
          "code": "3580023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 100.098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,OVAL 5.5X13CM AR-8550COE",
      "code_information": [
        {
          "code": "3580025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 815.7987,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3590000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1467,
          "minimum": 210.2058,
          "maximum": 1064.6019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 904.9116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTROSTOMY 18FR   100-18",
      "code_information": [
        {
          "code": "3590008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 233.1674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY BASIC         4380",
      "code_information": [
        {
          "code": "3590013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 301,
          "minimum": 102.9013,
          "maximum": 218.4357,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.6703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSAL 10FR  15642-001",
      "code_information": [
        {
          "code": "3590100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 385.3773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REPAIR ASH CATH      RPK01",
      "code_information": [
        {
          "code": "3590134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 693,
          "minimum": 207.4253,
          "maximum": 502.9101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 427.4736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 99.5419,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LMH LMH-1001",
      "code_information": [
        {
          "code": "3598009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 207.4253,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1656.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 03.130.302",
      "code_information": [
        {
          "code": "3598013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 2920.6372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-BLUE RHINO G2",
      "code_information": [
        {
          "code": "3598017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1759.8588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-STERLING 3.0X60X150",
      "code_information": [
        {
          "code": "3598023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1841,
          "minimum": 41.7075,
          "maximum": 1336.0137,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1135.6116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORGANIZER-7 DAY PILL 70069L",
      "code_information": [
        {
          "code": "3598024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 78.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.2634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I-KNIFE II 8065921502",
      "code_information": [
        {
          "code": "3598025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 142,
          "minimum": 48.5448,
          "maximum": 103.0494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPEN KNEE ABS-2001-OT",
      "code_information": [
        {
          "code": "3598069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 4266.3992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2957.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE GEL",
      "code_information": [
        {
          "code": "3598076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 41.1514,
          "maximum": 181.425,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 154.2113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACEMENT GEL",
      "code_information": [
        {
          "code": "3598077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 139.025,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.6465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER GEL",
      "code_information": [
        {
          "code": "3598078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 85.4662,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 154.2113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-SAMPLE EXTENSION 1841-25",
      "code_information": [
        {
          "code": "3598081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 6399.5988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-8MM ENT TUBE NVM5 2010480",
      "code_information": [
        {
          "code": "3598086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2289,
          "minimum": 782.5287,
          "maximum": 15669.2297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1411.9582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-9WX7L AR-8717-0907",
      "code_information": [
        {
          "code": "3598104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 32790.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-MEGADYNE 10FT SMOKE",
      "code_information": [
        {
          "code": "3598109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 55.61,
          "maximum": 169.0881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 143.7249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MEGADYNE F/SMOKE",
      "code_information": [
        {
          "code": "3598110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 196.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ZIP PEN F/SMOKE EVAC",
      "code_information": [
        {
          "code": "3598111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 121.0202,
          "maximum": 310.8599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 218.3631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER SO SPECTRUM SU",
      "code_information": [
        {
          "code": "3598112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 191.1025,
          "maximum": 405.6663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.8164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER S1 SPECTRUM SU",
      "code_information": [
        {
          "code": "3598113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 33.9221,
          "maximum": 405.6663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.8164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1603G",
      "code_information": [
        {
          "code": "3598114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 1661G",
      "code_information": [
        {
          "code": "3598115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.6465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MINIVAC MGVSFT10",
      "code_information": [
        {
          "code": "3598117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 454.8898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.1246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHTMAT-ULTRATHIN UA2550",
      "code_information": [
        {
          "code": "3598118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 818,
          "minimum": 279.6455,
          "maximum": 593.6226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 504.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MEGADYN SPECULUM 23951",
      "code_information": [
        {
          "code": "3598134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.6027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-221C-0427",
      "code_information": [
        {
          "code": "3598154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 5197.8667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 491.0086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLIDE-OCULAR KDB GLIDE",
      "code_information": [
        {
          "code": "3598156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 207.4253,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2049.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROVU DISP PHB-03",
      "code_information": [
        {
          "code": "3598158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11119,
          "minimum": 1230.6493,
          "maximum": 8069.0583,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6858.6996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BLUGRIGGS PERC DILATION",
      "code_information": [
        {
          "code": "3598159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2213,
          "minimum": 756.5469,
          "maximum": 5157.8275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1365.078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5X10 AR-8610TDC-01C",
      "code_information": [
        {
          "code": "3598172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 12007.8673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1448.9689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-EGG 4.0MM 5820-015-040",
      "code_information": [
        {
          "code": "3598178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 2.0 6007-1200",
      "code_information": [
        {
          "code": "3598184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 4999.339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY SZ 8 8DCFS",
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        {
          "code": "3598187",
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        {
          "code": "0270",
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        }
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        {
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          "minimum": 130.5924,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
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    {
      "description": "KIT-TUBT 7MM EMG ET 2010470",
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        {
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        {
          "code": "0270",
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        {
          "setting": "inpatient",
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          "minimum": 782.5287,
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          "payers_information": [
            {
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
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    },
    {
      "description": "BLADE-LAPIPLASTY 40X11 SM-4011",
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        {
          "code": "3598213",
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 204.0933,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
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    },
    {
      "description": "WIRE-K 3.2 HAMMER 702632",
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        {
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 870.8526,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
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      ],
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    },
    {
      "description": "KIT-FIBERTAK DS AR-8991DS",
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        {
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        {
          "code": "0270",
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      "standard_charges": [
        {
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          "maximum": 4743.533,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
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    {
      "description": "SUTURE-VICRYL 2-0 PLUS VCP317H",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM CSS-072-37-SQ",
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          "code": "3598257",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 1052.9907,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 895.0421,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-25 G00896",
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        {
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        {
          "code": "0270",
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        {
          "setting": "inpatient",
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          "minimum": 65.9799,
          "maximum": 1556.5239,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 119.0511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HIGH TORQUE 70-2001",
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        {
          "code": "3598282",
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 36.7026,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 850.0124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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    {
      "description": "SUTURE-MONOCRYL 3-0 MCP523H",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 22.5631,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 40.7118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "SUTURETAPE-1.3MM AR-7535",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 255.3731,
          "maximum": 1101.078,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 460.7832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYNGECTOMY SZ10 6132",
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        {
          "code": "3598291",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 46.7124,
          "maximum": 1700.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1445.2678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
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      "service_type": "CDM"
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    {
      "description": "NEBULIZER-PREFILL AREOSOL 500M",
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        {
          "code": "3598292",
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 28.7166,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "KIT-PUNCTURE 17FR/10MM 8141US",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 921.3258,
          "maximum": 8230.28,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1662.3973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORCAPOD SUCTION BIOPSY",
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        {
          "code": "3598300",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 46.1563,
          "maximum": 116.8377,
          "payers_information": [
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
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    {
      "description": "ELECTRODE-E-Z CLEAN 0016AM",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 28.3748,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    {
      "description": "BLADE-HELICAL 80M 04.038.380S",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "minimum": 1530.8708,
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          "payers_information": [
            {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "BAG-URINE METER 350ML 153204",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "minimum": 38.2889,
          "maximum": 8315.3633,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "SUTURE-2-0 SURGILON 8886195151",
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        {
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        {
          "code": "0270",
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      ],
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-3-0 SURGILON 8886195141",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 25.298,
          "maximum": 497.7095,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 45.6465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    {
      "description": "RESUSCITATOR-NEO TEE 1050810",
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        {
          "code": "0270",
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      ],
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        {
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          "minimum": 98.4571,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
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    {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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            {
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY L-WIRE 20115",
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        {
          "code": "0270",
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      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-LIGATING SURGITIE SGL-1",
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        },
        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
            {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 11 96\\\" Z880G",
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        },
        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-POWER 45MM FLEX PSEE45",
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        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 32FR 056132",
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        {
          "code": "3598409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 126.7908,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SOFSIK 2-0 18\\\" GS63M",
      "code_information": [
        {
          "code": "3598410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 165.4596,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 140.6407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOSOF 5-0 SN-661",
      "code_information": [
        {
          "code": "3598412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 36.2377,
          "maximum": 81.7467,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1 G48",
      "code_information": [
        {
          "code": "3598413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 7.7854,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.6762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0 3844G",
      "code_information": [
        {
          "code": "3598415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.1246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 714G",
      "code_information": [
        {
          "code": "3598417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD WARMING RAPID 24355",
      "code_information": [
        {
          "code": "3598418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 134.5762,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 272.6455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTOLOGY 2.3MMX240CM",
      "code_information": [
        {
          "code": "3598419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 78.4101,
          "maximum": 175.6194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.2765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY LONG 2.4MM E1450-6",
      "code_information": [
        {
          "code": "3598420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 7.7854,
          "maximum": 102.3237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.9751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y527H",
      "code_information": [
        {
          "code": "3598424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 239.123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-GRAVITY SPIKE FLUID MGMT",
      "code_information": [
        {
          "code": "3598425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 127.3469,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEM SILVER 6.5X7",
      "code_information": [
        {
          "code": "3598426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 166.1853,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.2575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 20FR 5CC",
      "code_information": [
        {
          "code": "3598427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 183.513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.9751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-J-TIP .035X145CM",
      "code_information": [
        {
          "code": "3598428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 330,
          "minimum": 81.1906,
          "maximum": 239.481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 203.5588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 30CC 16FR",
      "code_information": [
        {
          "code": "3598429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.0594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2 490T",
      "code_information": [
        {
          "code": "3598434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII BLADED CTB33",
      "code_information": [
        {
          "code": "3598436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM BLADELESS CTR03",
      "code_information": [
        {
          "code": "3598437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND 10FR DYNJWE1321A",
      "code_information": [
        {
          "code": "3598439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.2361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ULNAR NERVE 79-91100",
      "code_information": [
        {
          "code": "3598441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 947.0383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.0949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POWDER-HEMOSTAT AVITENE 1 GRAM",
      "code_information": [
        {
          "code": "3598442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1703,
          "minimum": 362.5772,
          "maximum": 1235.8671,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1050.487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RADIAL ARTERY 20GX1.75\\\"",
      "code_information": [
        {
          "code": "3598444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 265,
          "minimum": 90.5942,
          "maximum": 464.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 163.4639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL RHINO ROCKET LRG",
      "code_information": [
        {
          "code": "3598446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 368.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-FOREIGN BODY 60613",
      "code_information": [
        {
          "code": "3598447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 663,
          "minimum": 31.6977,
          "maximum": 481.1391,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.9682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 24FR 056124",
      "code_information": [
        {
          "code": "3598448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 121.2298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-HYDROFERA 6X6 HB6614",
      "code_information": [
        {
          "code": "3598449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 158.2026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 134.4722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SMALL WIDE",
      "code_information": [
        {
          "code": "3598450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 254.1377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.0891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARYNGECTOMY SZ6 6LGT",
      "code_information": [
        {
          "code": "3598451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 457,
          "minimum": 156.2322,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 281.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X285MM 703586",
      "code_information": [
        {
          "code": "3598458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 566,
          "minimum": 193.4955,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 566,
          "minimum": 193.4955,
          "maximum": 471.5728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 18FR",
      "code_information": [
        {
          "code": "3598463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 711.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.5081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 384.598,
          "maximum": 4441.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 693.9506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATFORM-GELPOINT PATH CNB11",
      "code_information": [
        {
          "code": "3598471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1687.4449,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3044.7469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VINYL CONNECTING G02791",
      "code_information": [
        {
          "code": "3598473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 78.9708,
          "maximum": 179.6203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 142.4912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRUIT, CROSS VENT 80011",
      "code_information": [
        {
          "code": "3598474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 323,
          "minimum": 110.4223,
          "maximum": 234.4011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.2409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR, NEO W/MASK",
      "code_information": [
        {
          "code": "3598475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 342,
          "minimum": 116.9178,
          "maximum": 533.2999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 210.961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3598478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 71.1808,
          "maximum": 565.3203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 480.5223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC #1 48G",
      "code_information": [
        {
          "code": "3598479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3287.6632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STEM 222-496100",
      "code_information": [
        {
          "code": "3598480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5912,
          "minimum": 2021.1051,
          "maximum": 4290.3384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3646.7876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRIP-PLATINUM MS04R-IP10X-0JH",
      "code_information": [
        {
          "code": "3598481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4118,
          "minimum": 1407.7995,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2540.1677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-ENDOCAPSULE 10 MAJ2027",
      "code_information": [
        {
          "code": "3598483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3003,
          "minimum": 402.6164,
          "maximum": 2179.2771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1852.3855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-10G/7.75\\\" 0306-810-000",
      "code_information": [
        {
          "code": "3598484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 724,
          "minimum": 247.5102,
          "maximum": 525.4068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 446.5958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77420",
      "code_information": [
        {
          "code": "3598485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 584,
          "minimum": 199.6491,
          "maximum": 30448.6994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 360.2375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/SUPPORT #6",
      "code_information": [
        {
          "code": "3598487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 784,
          "minimum": 268.0221,
          "maximum": 568.9488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 483.6065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST 4050-100N",
      "code_information": [
        {
          "code": "3598488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 1676.0854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 435.4926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-GONIOTOMY TRABEX 600042",
      "code_information": [
        {
          "code": "3598489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3014,
          "minimum": 784.101,
          "maximum": 2187.2598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1859.1708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-STRAIGHT JAW NSLX137S",
      "code_information": [
        {
          "code": "3598493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2542,
          "minimum": 869.0205,
          "maximum": 1844.7294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1568.02,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW NSLX137C",
      "code_information": [
        {
          "code": "3598494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2637,
          "minimum": 901.4976,
          "maximum": 1913.6709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1626.6203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JADA POSTPARTUM",
      "code_information": [
        {
          "code": "3598497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5844,
          "minimum": 1997.8582,
          "maximum": 5012.6854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3604.8422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA G PROCEDURAL PUG",
      "code_information": [
        {
          "code": "3598498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9014,
          "minimum": 580.0123,
          "maximum": 6541.4598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5560.2408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-4MM/SHORT 1149.8052",
      "code_information": [
        {
          "code": "3598502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 872.0973,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1573.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN",
      "code_information": [
        {
          "code": "3598508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94975",
      "code_information": [
        {
          "code": "3598515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1030,
          "minimum": 352.1208,
          "maximum": 747.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 635.3503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYN W/EL SZ10 6136",
      "code_information": [
        {
          "code": "3598520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4004,
          "minimum": 245.7962,
          "maximum": 2905.7028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2469.8474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.4X100/LG AGK10100",
      "code_information": [
        {
          "code": "3598521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 1475.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 272.6455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X120MM 45302001",
      "code_information": [
        {
          "code": "3598524",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 243.0369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNIT-TI-KNOT QUICK LOAD 030510",
      "code_information": [
        {
          "code": "3598527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PICO 14 WOUND 15X30CM",
      "code_information": [
        {
          "code": "3598530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1724,
          "minimum": 589.375,
          "maximum": 1251.1068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1063.4408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1590,
          "minimum": 543.5651,
          "maximum": 2600.3236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 980.7835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY STANDARD 7607",
      "code_information": [
        {
          "code": "3598534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1347,
          "minimum": 42.8197,
          "maximum": 977.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 830.8902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND XTRASORB 6X9",
      "code_information": [
        {
          "code": "3598535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 1016.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1828,
          "minimum": 32.2538,
          "maximum": 1326.5796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1127.5927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS SELECT",
      "code_information": [
        {
          "code": "3598538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 831.9256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY",
      "code_information": [
        {
          "code": "3598539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1496,
          "minimum": 511.4298,
          "maximum": 1085.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 922.8001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LK/MD 3.1X328 705077",
      "code_information": [
        {
          "code": "3598547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1526,
          "minimum": 207.4253,
          "maximum": 1107.4182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 941.3055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E-CATH PLUS 251285-41E",
      "code_information": [
        {
          "code": "3598551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 14240.6088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-OVAL CUP BIOPSY SINGLE",
      "code_information": [
        {
          "code": "3598561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 424.5345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 360.8543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEATED W/GAS FILTER",
      "code_information": [
        {
          "code": "3598562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 652,
          "minimum": 222.8959,
          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 402.1829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-10X360/RT/130* 3430-0360S",
      "code_information": [
        {
          "code": "3598565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6277,
          "minimum": 933.1358,
          "maximum": 4555.2189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3871.9361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X65MM 03.130.201",
      "code_information": [
        {
          "code": "3598592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1114,
          "minimum": 380.8375,
          "maximum": 808.4298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 687.1653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-AIRSEAL CANN 8MM IAS8-DV",
      "code_information": [
        {
          "code": "3598593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1123,
          "minimum": 383.9142,
          "maximum": 814.9611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.7169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTERD FURCATED ASM-EVAC",
      "code_information": [
        {
          "code": "3598594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1123,
          "minimum": 383.9142,
          "maximum": 1056.59,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.7169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS + MAP152",
      "code_information": [
        {
          "code": "3598601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 1228.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.6027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRIVE T6 VARIAX2 705132",
      "code_information": [
        {
          "code": "3598602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2210,
          "minimum": 755.5213,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1363.2274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREW T7 AO 45-27015",
      "code_information": [
        {
          "code": "3598609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1540,
          "minimum": 526.4719,
          "maximum": 3684.1625,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 949.9413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROXIMATE PROCEDURE PPH03",
      "code_information": [
        {
          "code": "3598617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2668,
          "minimum": 556.6561,
          "maximum": 1936.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1645.7425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X7MM 60-16007",
      "code_information": [
        {
          "code": "3598624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1349,
          "minimum": 461.1757,
          "maximum": 1138.3367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 832.1239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.9X115/35MM 92-19135",
      "code_information": [
        {
          "code": "3598625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2047,
          "minimum": 699.7974,
          "maximum": 1485.5079,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1262.6817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 9787.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 4627.8642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 162.2302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-EDIPURAL 17GX3.5 BUPIV",
      "code_information": [
        {
          "code": "3598647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 362,
          "minimum": 99.5419,
          "maximum": 262.7034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.2979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 0.3MM DWD055",
      "code_information": [
        {
          "code": "3598653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1389,
          "minimum": 207.4253,
          "maximum": 1007.9973,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 856.7977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #2",
      "code_information": [
        {
          "code": "3598662",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 90.0882,
          "maximum": 600.8796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.7477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDICLE ACCESS 624.027S",
      "code_information": [
        {
          "code": "3598668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 1542.8361,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2783.8215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3598678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 974,
          "minimum": 270.2646,
          "maximum": 706.8318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 600.807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 24FR 77424",
      "code_information": [
        {
          "code": "3598679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 486,
          "minimum": 166.1463,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 299.7867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X13MM AR-300-B001",
      "code_information": [
        {
          "code": "3598688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2343,
          "minimum": 800.9894,
          "maximum": 1700.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1445.2678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X19.5MM AR-300-B201",
      "code_information": [
        {
          "code": "3598689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2396,
          "minimum": 819.1082,
          "maximum": 1738.7772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1477.9606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8710H",
      "code_information": [
        {
          "code": "3598695",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 272,
          "minimum": 92.9872,
          "maximum": 214.0985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.7818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8725H",
      "code_information": [
        {
          "code": "3598696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 385,
          "minimum": 131.618,
          "maximum": 279.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.4853,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8806H",
      "code_information": [
        {
          "code": "3598697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.3904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8718H",
      "code_information": [
        {
          "code": "3598698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 187.2306,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8714H",
      "code_information": [
        {
          "code": "3598699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 215,
          "minimum": 73.5009,
          "maximum": 460.4508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 132.6217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W SPPRT MXPRSK05",
      "code_information": [
        {
          "code": "3598700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 283.0641,
          "maximum": 31654.8803,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.7477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-BENSTON 260CM/.035\\\"",
      "code_information": [
        {
          "code": "3598702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.7711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/ SUPPORT #3",
      "code_information": [
        {
          "code": "3598704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 283.0641,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.7477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-LT 130°/10X420 3530-0420S",
      "code_information": [
        {
          "code": "3598705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6277,
          "minimum": 2145.8857,
          "maximum": 4555.2189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3871.9361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-XI 45MM 480445",
      "code_information": [
        {
          "code": "3598714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3242,
          "minimum": 7.7854,
          "maximum": 2352.7194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1999.8115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-MUSTANG 7.0X20X135CM",
      "code_information": [
        {
          "code": "3598729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 840.1429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT,ACTIVE ANKLE HEEL-LOCK",
      "code_information": [
        {
          "code": "3598758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 464,
          "minimum": 150.7031,
          "maximum": 336.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 286.2161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR,SURGICEL 3123SPEA",
      "code_information": [
        {
          "code": "3598761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 322,
          "minimum": 110.0805,
          "maximum": 2901.7298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP ESREC",
      "code_information": [
        {
          "code": "3598782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 3.0X2.1 45-30005",
      "code_information": [
        {
          "code": "3598799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1849,
          "minimum": 632.1081,
          "maximum": 1341.8193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1140.5464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAC 425840405",
      "code_information": [
        {
          "code": "3598801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-8737-37",
      "code_information": [
        {
          "code": "3598812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE,.045\\\" THD AR-8737-05",
      "code_information": [
        {
          "code": "3598815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 7942.7763,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.8198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO 2.0MM DC6106",
      "code_information": [
        {
          "code": "3598843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 199.0838,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1076.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.5X150MM 58862515",
      "code_information": [
        {
          "code": "3598844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM DSDS1011",
      "code_information": [
        {
          "code": "3598845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.5MM DSDS0025",
      "code_information": [
        {
          "code": "3598846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1175.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.0MM DSDS0030",
      "code_information": [
        {
          "code": "3598853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1175.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR SHEEHY 510-131C",
      "code_information": [
        {
          "code": "3598870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 148.7685,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F X-FIT 60-80323",
      "code_information": [
        {
          "code": "3598874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1052.9907,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 895.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F 1.7MM 60-80317",
      "code_information": [
        {
          "code": "3598875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 895.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EAR-SPEEDIWICK 15MM OT-5201-50",
      "code_information": [
        {
          "code": "3598882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 15CM APYX-15-TP",
      "code_information": [
        {
          "code": "3598955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3007,
          "minimum": 1027.9876,
          "maximum": 2182.1799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1854.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERIOTOMY",
      "code_information": [
        {
          "code": "3598957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 207.4253,
          "maximum": 640.7931,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 544.6741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/46-62\\\" 1143PP",
      "code_information": [
        {
          "code": "3598975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 6.0 BIPOLAR",
      "code_information": [
        {
          "code": "3598997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2604,
          "minimum": 890.2161,
          "maximum": 3668.0356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1606.2644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 004025",
      "code_information": [
        {
          "code": "3599029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 91.4382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-WIGGLE OPTIFLOW JR 2 M",
      "code_information": [
        {
          "code": "3599030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 10911.2381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.65MM MD 45303065",
      "code_information": [
        {
          "code": "3599049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.55MM MD 45303055",
      "code_information": [
        {
          "code": "3599050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8305H",
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        {
          "code": "3599073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 1132.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.0238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-S-CURVE URETH DIL G32789",
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        {
          "code": "3599074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2036,
          "minimum": 696.0369,
          "maximum": 1477.5252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1255.8964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5x57MM 03.130.211",
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        {
          "code": "3599095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
      "code_information": [
        {
          "code": "3599096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5613,
          "minimum": 1918.8875,
          "maximum": 4073.3541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3462.351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002352",
      "code_information": [
        {
          "code": "3599098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2262,
          "minimum": 773.2983,
          "maximum": 1641.5334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1395.3034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002351",
      "code_information": [
        {
          "code": "3599099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2262,
          "minimum": 773.2983,
          "maximum": 1641.5334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1395.3034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-BEADED 3MM 4150004030",
      "code_information": [
        {
          "code": "3599100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1947,
          "minimum": 665.6109,
          "maximum": 1412.9379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1200.9972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LONG ENCOMPASS JAW OLH",
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        {
          "code": "3599110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 22744,
          "minimum": 7775.3744,
          "maximum": 16505.3208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 14029.5227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
      "code_information": [
        {
          "code": "3599114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4881,
          "minimum": 1668.6424,
          "maximum": 3600.7475,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3010.8204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-270-330C ALLOX-FH12SE",
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        {
          "code": "3599115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6475,
          "minimum": 207.4253,
          "maximum": 4698.9075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3994.0714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.3MM CSS-040-23",
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        {
          "code": "3599133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 9651.6716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-NAIL 3MM 4150004025",
      "code_information": [
        {
          "code": "3599135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1947,
          "minimum": 665.6109,
          "maximum": 1412.9379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1200.9972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-FULL VIP1137430",
      "code_information": [
        {
          "code": "3599140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FILL VIP1137431",
      "code_information": [
        {
          "code": "3599141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 284,
          "minimum": 97.0896,
          "maximum": 206.0988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #4",
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        {
          "code": "3599144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 870,
          "minimum": 297.4224,
          "maximum": 631.359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 536.6551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-HINGED KNEE LG 11-0672-4",
      "code_information": [
        {
          "code": "3599145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 872,
          "minimum": 207.4253,
          "maximum": 632.8104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 537.8888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-PROCESSOR DEPTH Z179994",
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        {
          "code": "3599155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2423,
          "minimum": 828.3386,
          "maximum": 32205.4193,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1494.6154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X230/200MM 315.93",
      "code_information": [
        {
          "code": "3599157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1826,
          "minimum": 624.2452,
          "maximum": 11446.7624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1126.359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TENSIONER-CERCLAGE AR-7820",
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        {
          "code": "3599172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2030,
          "minimum": 693.9857,
          "maximum": 1473.171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1252.1953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CERCLAGE STR/LG AR-7822",
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        {
          "code": "3599173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 533.2999,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1024.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-INS MID/HINDFOOT FFSP1530",
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        {
          "code": "3599178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 4705.7182,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1552.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LP PRP LEUKOCYTE POOR PRS6",
      "code_information": [
        {
          "code": "3599190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3723,
          "minimum": 1272.7629,
          "maximum": 2701.7811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2296.5139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-4160-40",
      "code_information": [
        {
          "code": "3599227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 398.1676,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 804.9827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SET RENOVARP GIS-30",
      "code_information": [
        {
          "code": "3599230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 5458.1215,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/135X45 03.133.102",
      "code_information": [
        {
          "code": "3599237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1522,
          "minimum": 274.1573,
          "maximum": 1104.5154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 938.8381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-100.783+/3H 954-0035",
      "code_information": [
        {
          "code": "3599249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1448,
          "minimum": 423.7482,
          "maximum": 1050.8136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 893.1916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PARACENTESIS GIS-31",
      "code_information": [
        {
          "code": "3599291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 132.3518,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 579.8343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MALE EXT PWM-030 PUREWICK",
      "code_information": [
        {
          "code": "3599292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 238,
          "minimum": 40.0392,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 146.8091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 2 1/2\\\"",
      "code_information": [
        {
          "code": "3599298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.4128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 3\\\"",
      "code_information": [
        {
          "code": "3599299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-PLANTAR KERATOSIS WOMENS",
      "code_information": [
        {
          "code": "3599300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" SMALL",
      "code_information": [
        {
          "code": "3599306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" MEDIUM",
      "code_information": [
        {
          "code": "3599307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" LARGE",
      "code_information": [
        {
          "code": "3599308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 53.7018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.6465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE DOUBLE",
      "code_information": [
        {
          "code": "3599309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE SINGLE",
      "code_information": [
        {
          "code": "3599310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE LEFT",
      "code_information": [
        {
          "code": "3599311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 69.6672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE RIGHT",
      "code_information": [
        {
          "code": "3599312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 139.5811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 25GX5”",
      "code_information": [
        {
          "code": "3599313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 251,
          "minimum": 85.8081,
          "maximum": 576.6757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 154.8281,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3599314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1037,
          "minimum": 354.5139,
          "maximum": 1007.6532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 639.6683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXYGENATOR-PERFUSION 050715",
      "code_information": [
        {
          "code": "3599315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1812,
          "minimum": 619.4591,
          "maximum": 1314.9684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1117.7231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-Y TYPE PERFUSION 10004",
      "code_information": [
        {
          "code": "3599362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 24440.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.8992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 19G X 1.5\\\"CT",
      "code_information": [
        {
          "code": "3599369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 1325.1863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM TUBING 8H23R12",
      "code_information": [
        {
          "code": "3599370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2383,
          "minimum": 814.664,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1469.9416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.7/125MM 03.133.105",
      "code_information": [
        {
          "code": "3599378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1325,
          "minimum": 452.9709,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 817.3196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-PIECE-OXYGEN MONITOR",
      "code_information": [
        {
          "code": "3599381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.1329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 5ML GIS-55",
      "code_information": [
        {
          "code": "3599412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 122.342,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-FINGER XL A8685",
      "code_information": [
        {
          "code": "3599413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 180.7325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.7059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY 040-300",
      "code_information": [
        {
          "code": "3599414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 811.906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 200.4746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RET 5MM/155CM FB-231D.A",
      "code_information": [
        {
          "code": "3599417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 6469.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/135X45 03.133.106",
      "code_information": [
        {
          "code": "3599424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1497,
          "minimum": 511.7717,
          "maximum": 1665.5195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 923.417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL N8 PROCESSOR DUALN8",
      "code_information": [
        {
          "code": "3599512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62546,
          "minimum": 501.0461,
          "maximum": 45389.6322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38581.1874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0 EPM8703",
      "code_information": [
        {
          "code": "3599513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 901,
          "minimum": 308.0202,
          "maximum": 1582.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 555.7773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.002",
      "code_information": [
        {
          "code": "3599527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 944,
          "minimum": 322.7204,
          "maximum": 48174.3869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 582.3017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOYSTICK-RED 5MM 03.211.454",
      "code_information": [
        {
          "code": "3599531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2911,
          "minimum": 497.7095,
          "maximum": 2112.5127,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1795.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IABC 40CC 7FR IMU7F-40",
      "code_information": [
        {
          "code": "3599539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5359,
          "minimum": 870.8526,
          "maximum": 3889.0263,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3305.6724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-SD 2MM T6 313.843.V",
      "code_information": [
        {
          "code": "3599548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1853,
          "minimum": 633.4756,
          "maximum": 1344.7221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1143.0138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIX 1.1MM DC4212",
      "code_information": [
        {
          "code": "3599593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1180,
          "minimum": 403.4005,
          "maximum": 1048.8046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 727.8771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 70MM",
      "code_information": [
        {
          "code": "3599601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.9858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 100MM",
      "code_information": [
        {
          "code": "3599602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.9858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE SMALL",
      "code_information": [
        {
          "code": "3599607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.0973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE MEDIUM",
      "code_information": [
        {
          "code": "3599608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.0973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE LARGE",
      "code_information": [
        {
          "code": "3599609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.0973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE X-LARGE",
      "code_information": [
        {
          "code": "3599610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.0973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 3520",
      "code_information": [
        {
          "code": "3599611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4030",
      "code_information": [
        {
          "code": "3599612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4540",
      "code_information": [
        {
          "code": "3599613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5040",
      "code_information": [
        {
          "code": "3599614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5550",
      "code_information": [
        {
          "code": "3599615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 35-40CM",
      "code_information": [
        {
          "code": "3599617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 293,
          "minimum": 100.1664,
          "maximum": 212.6301,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 180.7356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 40-45CM",
      "code_information": [
        {
          "code": "3599618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 293,
          "minimum": 100.1664,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 180.7356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE CVD AC-20055390",
      "code_information": [
        {
          "code": "3599638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1368,
          "minimum": 467.6711,
          "maximum": 992.7576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 843.844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE STRAIGHT",
      "code_information": [
        {
          "code": "3599639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1369,
          "minimum": 207.4253,
          "maximum": 993.4833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 844.4608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .315\\\" NAR 200138107S",
      "code_information": [
        {
          "code": "3599664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .50\\\" WIDE 200138108S",
      "code_information": [
        {
          "code": "3599666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 19559.7053,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-BONE SCREW IB200051",
      "code_information": [
        {
          "code": "3599670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1584,
          "minimum": 541.5139,
          "maximum": 4065.6471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 977.0825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDES-PT SPECIFIC PROPINF",
      "code_information": [
        {
          "code": "3599671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7311,
          "minimum": 311.9721,
          "maximum": 5305.5927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4509.7538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 2.4MM 200072",
      "code_information": [
        {
          "code": "3599672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 1123.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CORNER 4.8MM 33600048",
      "code_information": [
        {
          "code": "3599673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2020,
          "minimum": 272.489,
          "maximum": 1465.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1246.0269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACID-5% ACETIC 9045052",
      "code_information": [
        {
          "code": "3599696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 55.8789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL CARE DUOCARE MDS604DC",
      "code_information": [
        {
          "code": "3599708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 270.2646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.2658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3599751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.7118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-INTERSEPT 6031",
      "code_information": [
        {
          "code": "3599752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X1/4X1/4 Y 6036",
      "code_information": [
        {
          "code": "3599753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/2X3/8X3/8 6040",
      "code_information": [
        {
          "code": "3599754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.7118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PERFUSE 1/4\\\" 10007",
      "code_information": [
        {
          "code": "3599756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 3111.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/M P01-900-1703",
      "code_information": [
        {
          "code": "3599770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 870.8526,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1668.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH 82-1516",
      "code_information": [
        {
          "code": "3599774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1505,
          "minimum": 514.5066,
          "maximum": 1092.1785,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 928.3517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOPRO-VASOVIEW 2 VEIN",
      "code_information": [
        {
          "code": "3599778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6789,
          "minimum": 43.9319,
          "maximum": 4926.7773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4187.7607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 5F 20\\\"",
      "code_information": [
        {
          "code": "3599779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 57.3303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 6.5F 36\\\"",
      "code_information": [
        {
          "code": "3599780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 392.0505,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.7308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UNIVERSAL PALM MEDIUM",
      "code_information": [
        {
          "code": "3599787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 128.4591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 17GX4.5\\\"",
      "code_information": [
        {
          "code": "3599788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 54.4978,
          "maximum": 167.6367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 142.4912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPACER IN-LINE 42-RTC24-VP",
      "code_information": [
        {
          "code": "3599789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 73.9613,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRIMARY DUOVENT 1424828",
      "code_information": [
        {
          "code": "3599790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 96.5181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-PED ANES W/FILTER",
      "code_information": [
        {
          "code": "3599791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 143,
          "minimum": 48.8867,
          "maximum": 2287.2393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.2088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 45MM",
      "code_information": [
        {
          "code": "3599808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2874,
          "minimum": 982.5196,
          "maximum": 2085.6618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1772.8125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 60MM",
      "code_information": [
        {
          "code": "3599809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3133,
          "minimum": 865.2916,
          "maximum": 2273.6181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1932.5754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 368,
          "minimum": 125.8063,
          "maximum": 267.0576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 226.999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 10CM SHORT",
      "code_information": [
        {
          "code": "3599881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 8CM SHORT",
      "code_information": [
        {
          "code": "3599882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 1067.712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-LP 2MMX4CM RBYLP0204",
      "code_information": [
        {
          "code": "3599885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4457,
          "minimum": 870.8526,
          "maximum": 3234.4449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2749.2782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.1X70 KWIRE 03.130.200",
      "code_information": [
        {
          "code": "3599922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 751.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5X7 STD AR-7350TD",
      "code_information": [
        {
          "code": "3599951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 378.7863,
          "maximum": 2659.8263,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 683.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY G 18FR 2.7",
      "code_information": [
        {
          "code": "3599960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 103.9907,
          "maximum": 711.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.5081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING DISP FG-600U",
      "code_information": [
        {
          "code": "3600018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 782,
          "minimum": 267.3383,
          "maximum": 7277.6807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 482.3728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT 10012",
      "code_information": [
        {
          "code": "3600074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 500.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.0238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/36 7413",
      "code_information": [
        {
          "code": "3600119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1452,
          "minimum": 37.2587,
          "maximum": 1053.7164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 895.6589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PROVOX XTRAFLOW HME",
      "code_information": [
        {
          "code": "3600120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 806.9011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 10/36",
      "code_information": [
        {
          "code": "3600121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 895.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORA/PARA 6FRTAPS-6F-12PT",
      "code_information": [
        {
          "code": "3600163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 835,
          "minimum": 207.4253,
          "maximum": 605.9595,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.0656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.3CM",
      "code_information": [
        {
          "code": "3600165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 605,
          "minimum": 206.8282,
          "maximum": 539.9731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 373.1912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNOTOMY 046-367",
      "code_information": [
        {
          "code": "3600166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 215.7668,
          "maximum": 704.6547,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 598.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER SM 4934-8-100",
      "code_information": [
        {
          "code": "3600215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH14 050179",
      "code_information": [
        {
          "code": "3600219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 183.513,
          "maximum": 704.6547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R501-26",
      "code_information": [
        {
          "code": "3600220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 330,
          "minimum": 112.8154,
          "maximum": 239.481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 203.5588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL XS EVF1XSLA",
      "code_information": [
        {
          "code": "3600221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 253,
          "minimum": 86.4918,
          "maximum": 183.6021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL S-M EVF1MSLA",
      "code_information": [
        {
          "code": "3600222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 253,
          "minimum": 86.4918,
          "maximum": 183.6021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL L EVF1LSLA",
      "code_information": [
        {
          "code": "3600223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 86.4918,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 156.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SMLSL",
      "code_information": [
        {
          "code": "3600229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 238,
          "minimum": 81.3638,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 146.8091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 8 5 165808",
      "code_information": [
        {
          "code": "3600233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 1325.1863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SZ 0 VLOCM2146",
      "code_information": [
        {
          "code": "3600255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 390,
          "minimum": 133.3273,
          "maximum": 325.3185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 240.5695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 BARBED VLOCL0615",
      "code_information": [
        {
          "code": "3600256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 1231.7615,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 360.8543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X285MM 703583",
      "code_information": [
        {
          "code": "3600270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R502-15",
      "code_information": [
        {
          "code": "3600272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT AR-11114",
      "code_information": [
        {
          "code": "3600273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 278,
          "minimum": 95.0384,
          "maximum": 260.2548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO 125MM AR-3210-0051",
      "code_information": [
        {
          "code": "3600300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 231.8937,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR,SUCTION 8MM 480299",
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        {
          "code": "3600302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1868,
          "minimum": 638.6036,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1152.2665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-2.3MM INLINE DRILL MOUTH",
      "code_information": [
        {
          "code": "3600308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2463,
          "minimum": 842.0132,
          "maximum": 6512.4871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1519.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SPIRAL 7000AAO",
      "code_information": [
        {
          "code": "3600310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 260.2548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ONESTEP 5F OSC-5F-12PT/C",
      "code_information": [
        {
          "code": "3600311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 468,
          "minimum": 159.9928,
          "maximum": 7277.6807,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 288.6835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NASAL ETOC2 ADT",
      "code_information": [
        {
          "code": "3600315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 277,
          "minimum": 94.6966,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.8661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48MM EZOUT 7812-048-001K",
      "code_information": [
        {
          "code": "3600316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3131.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-50MM EZOUT 7812-050-001K",
      "code_information": [
        {
          "code": "3600317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 210.2058,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3131.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC/SAG 5.5 2296-023-412",
      "code_information": [
        {
          "code": "3600318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 1450.8649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 233.1674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FAT TRANS VIALITY-1400",
      "code_information": [
        {
          "code": "3600331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1097.1853,
          "maximum": 2456.4945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3600343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 2223.2878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL 3.5/2.5 AR-8943-14",
      "code_information": [
        {
          "code": "3600344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3998,
          "minimum": 232.4498,
          "maximum": 2901.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2466.1463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 MONOTEX T8623",
      "code_information": [
        {
          "code": "3600351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-VISION SUCTION PROBE",
      "code_information": [
        {
          "code": "3600353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 182.9569,
          "maximum": 433.2429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-VISION PROBE ION 490127",
      "code_information": [
        {
          "code": "3600354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 19G BIOPSY",
      "code_information": [
        {
          "code": "3600355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 21G BIOPSY",
      "code_information": [
        {
          "code": "3600356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 23G BIOPSY",
      "code_information": [
        {
          "code": "3600357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 98.9858,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 14-16FR",
      "code_information": [
        {
          "code": "3600358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 178,
          "minimum": 60.8519,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 109.7984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-ION SWIVEL",
      "code_information": [
        {
          "code": "3600359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 22602.1284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 837.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 5X356/126MM 03.008.008",
      "code_information": [
        {
          "code": "3600375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1921,
          "minimum": 580.0123,
          "maximum": 1394.0697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1184.9592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROC 2.3X230 P99-194-2323",
      "code_information": [
        {
          "code": "3600390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 958.1603,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3600412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 840.1429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUMIDIFIER-CPAP HC325S",
      "code_information": [
        {
          "code": "3600428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 444.88,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE M001141006",
      "code_information": [
        {
          "code": "3600430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1293,
          "minimum": 442.0313,
          "maximum": 3176.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 797.5806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-2-2.7MM 706200",
      "code_information": [
        {
          "code": "3600436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 869.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-8MM/SD LORD 1088-43-008",
      "code_information": [
        {
          "code": "3600449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2435.9209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER FLX 4150016000",
      "code_information": [
        {
          "code": "3600467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4998,
          "minimum": 1708.6406,
          "maximum": 9651.6716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3082.9913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-9X250 STP 4150002090",
      "code_information": [
        {
          "code": "3600471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 10446.8946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1341.6379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-FETAL C-SECTION",
      "code_information": [
        {
          "code": "3600474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5613,
          "minimum": 546.0902,
          "maximum": 4073.3541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3462.351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-BAND POLY CFI-733",
      "code_information": [
        {
          "code": "3600493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 1676.0854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.1139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PUMP 8\\\" AR-6411",
      "code_information": [
        {
          "code": "3600498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 261.5266,
          "maximum": 555.1605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 471.8864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC OUTFLOW AR-6435",
      "code_information": [
        {
          "code": "3600499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 752,
          "minimum": 257.0824,
          "maximum": 2799.9635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 463.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY M00516071",
      "code_information": [
        {
          "code": "3600502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 820.8036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 132.0048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VEIN HARVEST VASOVIEW",
      "code_information": [
        {
          "code": "3600503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1476,
          "minimum": 207.4253,
          "maximum": 1071.1332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 910.4632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURSPLEX DART300 NASAL",
      "code_information": [
        {
          "code": "3600506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 77.854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.1139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURAPLEX DART-REACH600",
      "code_information": [
        {
          "code": "3600507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY O40-403",
      "code_information": [
        {
          "code": "3600508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 4.6X340 P99-110-4634",
      "code_information": [
        {
          "code": "3600519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 207.4253,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1726.5492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 11X200 4922-8-200",
      "code_information": [
        {
          "code": "3600545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1786,
          "minimum": 610.5706,
          "maximum": 1296.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1101.6852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HEMOCON PERF 020271801",
      "code_information": [
        {
          "code": "3600548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 842,
          "minimum": 287.8502,
          "maximum": 5717.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 519.3835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-SINGLE NEOPRENE M8138",
      "code_information": [
        {
          "code": "3600550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 47.2685,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION ADULT",
      "code_information": [
        {
          "code": "3600551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 61.6845,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.4318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION PED",
      "code_information": [
        {
          "code": "3600552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 68.4003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.4318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383592",
      "code_information": [
        {
          "code": "3600553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG STRT AR-7821",
      "code_information": [
        {
          "code": "3600561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1024.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 10FL AR-9280NOT",
      "code_information": [
        {
          "code": "3600562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 378.7863,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 683.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-NANO 2.8X11 AR-9280NSR",
      "code_information": [
        {
          "code": "3600563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 378.7863,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 683.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-HP EVAC 70 E1CA5874-01",
      "code_information": [
        {
          "code": "3600565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2197,
          "minimum": 751.0771,
          "maximum": 1594.3629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1355.2085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-EVAC 70 EICA5872-01",
      "code_information": [
        {
          "code": "3600567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2097,
          "minimum": 716.8906,
          "maximum": 1521.7929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE XP EICA8872-01",
      "code_information": [
        {
          "code": "3600568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2093,
          "minimum": 715.5232,
          "maximum": 8030.6401,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1291.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PURPLE",
      "code_information": [
        {
          "code": "3600570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY PURPLE",
      "code_information": [
        {
          "code": "3600571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PINK/RED",
      "code_information": [
        {
          "code": "3600574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY YELLOW",
      "code_information": [
        {
          "code": "3600575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 173.4423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY WHITE",
      "code_information": [
        {
          "code": "3600576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION WHITE",
      "code_information": [
        {
          "code": "3600577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION BLUE",
      "code_information": [
        {
          "code": "3600579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION ORANGE",
      "code_information": [
        {
          "code": "3600580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY ORANGE",
      "code_information": [
        {
          "code": "3600581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION GREEN",
      "code_information": [
        {
          "code": "3600582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 455.4459,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GUIDE 95CM/9FR STRT",
      "code_information": [
        {
          "code": "3600599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1175.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 16MM P45-914-0001",
      "code_information": [
        {
          "code": "3600607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-XL 10MM HEX P45-941-0001",
      "code_information": [
        {
          "code": "3600609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 420.0714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT P45-170-1000",
      "code_information": [
        {
          "code": "3600610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 870.8526,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4167.4048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MEASURE STOMA MIC-KEY",
      "code_information": [
        {
          "code": "3600617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.1329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENTERAL FEEDING LITE",
      "code_information": [
        {
          "code": "3600618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.1246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-FARREL ENTERAL W BAG",
      "code_information": [
        {
          "code": "3600619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 786.8815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.7MM AR-7511",
      "code_information": [
        {
          "code": "3600664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 901.4381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 WHITE 48360W",
      "code_information": [
        {
          "code": "3600665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 999.9057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLUE 48360B",
      "code_information": [
        {
          "code": "3600666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 999.9057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 GREEN 48360G",
      "code_information": [
        {
          "code": "3600667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 999.9057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLACK 48360T",
      "code_information": [
        {
          "code": "3600668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 999.9057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-PORTABLE DEVILBISS",
      "code_information": [
        {
          "code": "3600669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2011,
          "minimum": 32.2538,
          "maximum": 1459.3827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1240.4753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WATER-STERILE INHALATION 500ML",
      "code_information": [
        {
          "code": "3600670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 1121.0976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-14FR SU130-1239",
      "code_information": [
        {
          "code": "3600671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2016,
          "minimum": 689.1996,
          "maximum": 1463.0112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1243.5595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-16FR SU130-1240",
      "code_information": [
        {
          "code": "3600672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2016,
          "minimum": 689.1996,
          "maximum": 6323.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1243.5595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-12mm 47050",
      "code_information": [
        {
          "code": "3600674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 333.66,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X185MM 2351-4218S",
      "code_information": [
        {
          "code": "3600681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 801.8985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 1.7MM DSDS0017",
      "code_information": [
        {
          "code": "3600688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1175.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2MM DSDS0020",
      "code_information": [
        {
          "code": "3600689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 272.489,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1175.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3600708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1042,
          "minimum": 356.2232,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 642.7525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.6X150MM AR-8741-16",
      "code_information": [
        {
          "code": "3600710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 209.905,
          "maximum": 1371.8987,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 378.7428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,-TR 2X8MM AR-300-B002",
      "code_information": [
        {
          "code": "3600711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 1790.3019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1521.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION AR-200",
      "code_information": [
        {
          "code": "3600717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 243.0369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-3.7MM DRILL AR-2272",
      "code_information": [
        {
          "code": "3600719",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1425,
          "minimum": 487.1574,
          "maximum": 4598.3909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 879.0041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO POLY M-L 51114V",
      "code_information": [
        {
          "code": "3600722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 93.4248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.1139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.102",
      "code_information": [
        {
          "code": "3600736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 25181.3202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 X806H",
      "code_information": [
        {
          "code": "3600739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 4854.1969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.2171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN PVC 24FR",
      "code_information": [
        {
          "code": "3600749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 746.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.5623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANCHOR-ENTUIT SUTURE G35562",
      "code_information": [
        {
          "code": "3600750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1342,
          "minimum": 431.5336,
          "maximum": 973.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 827.806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LEAD-CATH 4FR 38 383069",
      "code_information": [
        {
          "code": "3600757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 23820.5435,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1635.2561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-NITINOL 2.0MM",
      "code_information": [
        {
          "code": "3600759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6MM MXM-072-16",
      "code_information": [
        {
          "code": "3600767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1109.7042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6 MXM-072-ISO-16",
      "code_information": [
        {
          "code": "3600768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1109.7042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RCC RMH-T015S",
      "code_information": [
        {
          "code": "3600773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 904,
          "minimum": 309.0458,
          "maximum": 3144.7455,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXOFIN FUSION EF70430",
      "code_information": [
        {
          "code": "3600781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 976,
          "minimum": 62.2832,
          "maximum": 708.2832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 602.0407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 MONOTEX FS-2 T8665",
      "code_information": [
        {
          "code": "3600782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 300.294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA",
      "code_information": [
        {
          "code": "3600783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 333.0963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "XTRAFLANGE-PROVOX 20 FR 7276",
      "code_information": [
        {
          "code": "3600784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 1084.9511,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 333.0963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20 FR 6MM 8277",
      "code_information": [
        {
          "code": "3600785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1951,
          "minimum": 666.9783,
          "maximum": 1622.6998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1203.4646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2006-NS",
      "code_information": [
        {
          "code": "3600786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1799.9537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-NS",
      "code_information": [
        {
          "code": "3600787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1799.9537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7FR 4",
      "code_information": [
        {
          "code": "3600789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7F 34",
      "code_information": [
        {
          "code": "3600790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 722.93,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE 4.2X130 2351-4213S",
      "code_information": [
        {
          "code": "3600791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 801.8985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-LOCK 4.2X360 2351-4236S",
      "code_information": [
        {
          "code": "3600792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 801.8985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-CARDIOTOMY EL400",
      "code_information": [
        {
          "code": "3600858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 579,
          "minimum": 197.9398,
          "maximum": 670.6566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 357.1533,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 34CC LINEAR",
      "code_information": [
        {
          "code": "3600866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4523,
          "minimum": 1546.2548,
          "maximum": 3282.3411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2789.9899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 40CC MEGA 0",
      "code_information": [
        {
          "code": "3600867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4905,
          "minimum": 1676.8471,
          "maximum": 3559.5585,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3025.6247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 50CC MEGA 0",
      "code_information": [
        {
          "code": "3600868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4905,
          "minimum": 1676.8471,
          "maximum": 3559.5585,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3025.6247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-8\\\" THD AR-8967KT",
      "code_information": [
        {
          "code": "3600879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 836.3744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1 LMA",
      "code_information": [
        {
          "code": "3600899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-STR 4MM P1-AU511",
      "code_information": [
        {
          "code": "3600906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7067,
          "minimum": 45.6002,
          "maximum": 5128.5219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4359.2436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1.5 LMA",
      "code_information": [
        {
          "code": "3600907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 59.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 3 LMA",
      "code_information": [
        {
          "code": "3600908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 5 LMA",
      "code_information": [
        {
          "code": "3600909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 2 LMA",
      "code_information": [
        {
          "code": "3600910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS MED TRACTION",
      "code_information": [
        {
          "code": "3600912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS LG TRACTION",
      "code_information": [
        {
          "code": "3600913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS SM TRACTION",
      "code_information": [
        {
          "code": "3600914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 64.5076,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 130187",
      "code_information": [
        {
          "code": "3600915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 6163.2563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SHRT SCREW 6149.1042",
      "code_information": [
        {
          "code": "3600925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EZX 54MM BRXTB540",
      "code_information": [
        {
          "code": "3600938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5636,
          "minimum": 1926.7504,
          "maximum": 6657.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3476.5384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX 45MM 227445500",
      "code_information": [
        {
          "code": "3600946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1795.0908,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-TOGA XL 0416-830-100",
      "code_information": [
        {
          "code": "3600948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 909,
          "minimum": 310.7552,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 560.7121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20F 10MM 8279",
      "code_information": [
        {
          "code": "3600952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1894,
          "minimum": 647.492,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1168.3044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS MALLEABLE 4MM",
      "code_information": [
        {
          "code": "3600954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 9196.7818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1341.6379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG LIGHT MED C02051",
      "code_information": [
        {
          "code": "3600964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 79.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG SMALL C020500",
      "code_information": [
        {
          "code": "3600965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 1673.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 228MM 56010228",
      "code_information": [
        {
          "code": "3600977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-JONES 3.2MM 56013200",
      "code_information": [
        {
          "code": "3600978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1175.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 5.5MM 56015500",
      "code_information": [
        {
          "code": "3600980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1584,
          "minimum": 541.5139,
          "maximum": 4020.603,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 977.0825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CRYOTHERAPY FGS-7000",
      "code_information": [
        {
          "code": "3600997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5867,
          "minimum": 75.0735,
          "maximum": 4257.6819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3619.0296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXHAUST COLLECT FGS-7015",
      "code_information": [
        {
          "code": "3600999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONN-X 5.5/32-40 LNG 1119.0034",
      "code_information": [
        {
          "code": "3601000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 1089.8652,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1966.5019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PREP 4.2MM 0909-100-042",
      "code_information": [
        {
          "code": "3601029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EXP 4.2MM 0909-200-042",
      "code_information": [
        {
          "code": "3601030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 389.27,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ XF 4.2MM 0909-400-400",
      "code_information": [
        {
          "code": "3601031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 700,
          "minimum": 239.3054,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.7915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 10MM 650.110",
      "code_information": [
        {
          "code": "3601032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CRV 4MM P1-AU550",
      "code_information": [
        {
          "code": "3601055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 2690.4764,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4854.5701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-360-430 ALLOX2-FH13SE",
      "code_information": [
        {
          "code": "3601056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7446,
          "minimum": 207.4253,
          "maximum": 5403.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4593.0279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACENTESIS/PARACENTESI",
      "code_information": [
        {
          "code": "3601066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 701,
          "minimum": 226.3327,
          "maximum": 508.7157,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 432.4083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G CMNT 0306-150-000",
      "code_information": [
        {
          "code": "3601086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 598,
          "minimum": 204.4352,
          "maximum": 433.9686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CMNT 11G 0306-330-000",
      "code_information": [
        {
          "code": "3601087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 642,
          "minimum": 219.4772,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 396.0145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TB AR-200",
      "code_information": [
        {
          "code": "3601096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 250.4391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRILL 3X320 P31-951-3032",
      "code_information": [
        {
          "code": "3601107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1963,
          "minimum": 671.0807,
          "maximum": 1556.5239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1210.8667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 7X200 P99-110-7019",
      "code_information": [
        {
          "code": "3601108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1726.5492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-110-4630",
      "code_information": [
        {
          "code": "3601109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1726.5492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.8X250 P99-100-3825",
      "code_information": [
        {
          "code": "3601110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1726.5492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-16 HLW 03.037.004S",
      "code_information": [
        {
          "code": "3601121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CENTRAL VENOUS PED",
      "code_information": [
        {
          "code": "3601123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 669,
          "minimum": 194.635,
          "maximum": 485.4933,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 412.6693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOD-PROTECTOR 69392",
      "code_information": [
        {
          "code": "3601124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 350,
          "minimum": 119.6527,
          "maximum": 253.995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.8957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT ADULT DISP 731",
      "code_information": [
        {
          "code": "3601125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 273,
          "minimum": 93.3291,
          "maximum": 198.1161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.3987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-VARISPEED 62-50201",
      "code_information": [
        {
          "code": "3601154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1913,
          "minimum": 653.9875,
          "maximum": 1388.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1180.0245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.5MM 72202189",
      "code_information": [
        {
          "code": "3601200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1735.5881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STR 14MM/SC 684.424",
      "code_information": [
        {
          "code": "3601216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2509.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SUCTION BALLARD 14FR",
      "code_information": [
        {
          "code": "3601234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 952.0432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.2741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 35FR 412351000",
      "code_information": [
        {
          "code": "3601235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1056.0386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 37FR 412371000",
      "code_information": [
        {
          "code": "3601236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1076.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 39FR 412391000",
      "code_information": [
        {
          "code": "3601237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1076.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER MD 4934-8-140",
      "code_information": [
        {
          "code": "3601242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-1.8X450 DIA PT 4933-8-010",
      "code_information": [
        {
          "code": "3601244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 682,
          "minimum": 233.1518,
          "maximum": 494.9274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 420.6883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 120MM 4933-1-120",
      "code_information": [
        {
          "code": "3601245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 527,
          "minimum": 180.1628,
          "maximum": 382.4439,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 325.0773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SCREW 6149.1040",
      "code_information": [
        {
          "code": "3601255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 42686.7921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-IV SW 3000ML BAG S8505",
      "code_information": [
        {
          "code": "3601260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 22040.4674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.5267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4MM CANN AR-8973-40S",
      "code_information": [
        {
          "code": "3601272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 963.5119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-PIN & PROT P45-610-1000",
      "code_information": [
        {
          "code": "3601289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 1074.9413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 255.9907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-10MM P47-950-0001",
      "code_information": [
        {
          "code": "3601290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1933,
          "minimum": 115.6688,
          "maximum": 1402.7781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1192.3614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-PROTECT P45-600-1000-S",
      "code_information": [
        {
          "code": "3601291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.3038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-AIR+MENISCAL CV 4722",
      "code_information": [
        {
          "code": "3601324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 870.8526,
          "maximum": 1851.2607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1573.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-GRAFT LG M00236320021",
      "code_information": [
        {
          "code": "3601349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 176,
          "minimum": 60.1682,
          "maximum": 157.3763,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.5647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC SMALL 313-9013W",
      "code_information": [
        {
          "code": "3601350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC MED 313-9014W",
      "code_information": [
        {
          "code": "3601351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-2.5 PRCSN MTCH HD 16CM",
      "code_information": [
        {
          "code": "3601354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1891,
          "minimum": 646.4665,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1166.4539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROCH 1.1MM AR-18700-30",
      "code_information": [
        {
          "code": "3601375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.8198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STEP SOLID 1806-3026S",
      "code_information": [
        {
          "code": "3601387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1432,
          "minimum": 489.5505,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 883.322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47522",
      "code_information": [
        {
          "code": "3601390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 909.3021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 772.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOCLOT EPK2303-01",
      "code_information": [
        {
          "code": "3601392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 329.2112,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-ENDOCLOT EA230",
      "code_information": [
        {
          "code": "3601393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 592,
          "minimum": 202.384,
          "maximum": 11794.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 365.1722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 12\\\" 3.2MM",
      "code_information": [
        {
          "code": "3601397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 399,
          "minimum": 136.4041,
          "maximum": 5711.147,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 246.1212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.25MM  AR-18800-35",
      "code_information": [
        {
          "code": "3601403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 851,
          "minimum": 290.927,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 524.9351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-10X16X8/12° 1213.6088S",
      "code_information": [
        {
          "code": "3601406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6769,
          "minimum": 2314.0832,
          "maximum": 4912.2633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4175.4238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 16X8MM 1128.2408",
      "code_information": [
        {
          "code": "3601407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 580.5684,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2783.8215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X14MM 184.014",
      "code_information": [
        {
          "code": "3601408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X16MM 184.016",
      "code_information": [
        {
          "code": "3601409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR SD 4.2X14MM 184.054",
      "code_information": [
        {
          "code": "3601410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI REFLUX",
      "code_information": [
        {
          "code": "3601418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-KANGAROO Y-PORT/PEG",
      "code_information": [
        {
          "code": "3601419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 58.056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 18FR 8887605189",
      "code_information": [
        {
          "code": "3601420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 20FR 8887605205",
      "code_information": [
        {
          "code": "3601421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 3586.2889,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IN/OUTFLOW AR-6436",
      "code_information": [
        {
          "code": "3601433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1031,
          "minimum": 352.4627,
          "maximum": 748.1967,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 635.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 53.9417,
          "maximum": 445.5798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 378.7428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G-TUBE ENFIT",
      "code_information": [
        {
          "code": "3601440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1234,
          "minimum": 392.6066,
          "maximum": 895.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 761.1867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG ENFIT 24FR M00509061",
      "code_information": [
        {
          "code": "3601441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 435.4926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5020",
      "code_information": [
        {
          "code": "3601445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 846,
          "minimum": 60.0588,
          "maximum": 613.9422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 521.8509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOCKWAVE STERILE CABLE",
      "code_information": [
        {
          "code": "3601446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 84.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16FR 20CM G01212",
      "code_information": [
        {
          "code": "3601447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-18FR 20CM G01328",
      "code_information": [
        {
          "code": "3601448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO JEJUNAL 8250-22",
      "code_information": [
        {
          "code": "3601452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1577,
          "minimum": 539.1209,
          "maximum": 1144.4289,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 972.7646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 8200-20",
      "code_information": [
        {
          "code": "3601453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 246.9084,
          "maximum": 1004.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.7135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10FR 50-7361",
      "code_information": [
        {
          "code": "3601454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 444,
          "minimum": 151.788,
          "maximum": 544.978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 273.8792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 18140",
      "code_information": [
        {
          "code": "3601455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 711.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.5081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DLP CORONARY 30315",
      "code_information": [
        {
          "code": "3601479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 510,
          "minimum": 174.3511,
          "maximum": 486.5875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 314.5909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 875,
          "minimum": 53.9417,
          "maximum": 634.9875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 539.7394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 14FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC DRG MN12050",
      "code_information": [
        {
          "code": "3601484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 42051.7259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1656.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PREFORM-S3-4 39+6MM DWP2396",
      "code_information": [
        {
          "code": "3601576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8123,
          "minimum": 2509.6793,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5010.6319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 18X7MM 1128.1507",
      "code_information": [
        {
          "code": "3601577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 1542.8361,
          "maximum": 17566.6429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2783.8215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-20X55 8-17 5° 1122.1055",
      "code_information": [
        {
          "code": "3601578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 31589,
          "minimum": 870.8526,
          "maximum": 22924.1373,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 19485.5167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 3X14 AR-8630-14",
      "code_information": [
        {
          "code": "3601580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.4208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 2.5X16 AR-8625-16",
      "code_information": [
        {
          "code": "3601581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 670.6566,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.4208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LP/CRT 1.6X9 AR-18716-09",
      "code_information": [
        {
          "code": "3601582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1206,
          "minimum": 230.7815,
          "maximum": 875.1942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 743.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CABLE PLATE 94-1200-08",
      "code_information": [
        {
          "code": "3601588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5867,
          "minimum": 2005.7211,
          "maximum": 4257.6819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3619.0296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AUX CBL PLT 94-1500-04-S",
      "code_information": [
        {
          "code": "3601589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 534.4121,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1195",
      "code_information": [
        {
          "code": "3601590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 836.3744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 592.788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ1 CN P2ND1001",
      "code_information": [
        {
          "code": "3601591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 514.1647,
          "maximum": 4843.631,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 927.7349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-PEDI DSG P2HE2000",
      "code_information": [
        {
          "code": "3601592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8710,
          "minimum": 870.8526,
          "maximum": 6320.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5372.7199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BALLARD/NEO BAA2103",
      "code_information": [
        {
          "code": "3601615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.4615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-DF 65MM/RT/STD 6495-2-040",
      "code_information": [
        {
          "code": "3601630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21681,
          "minimum": 1548.1824,
          "maximum": 15733.9017,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13373.8164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CN/CC 7X45MM 8040-045",
      "code_information": [
        {
          "code": "3601631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 497.7095,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.2965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-SMALL KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7523,
          "minimum": 2571.8493,
          "maximum": 5459.4411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4640.5249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-LARGE KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7523,
          "minimum": 1795.0908,
          "maximum": 5459.4411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4640.5249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-WOUND CROWN",
      "code_information": [
        {
          "code": "3601647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 571.8516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 486.0739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN RAL 6MM B02236010",
      "code_information": [
        {
          "code": "3601652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 1826.5869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1552.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN STD 6MM B02236001",
      "code_information": [
        {
          "code": "3601653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 7992.8253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1552.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL LK 3.5 AR-8943-43",
      "code_information": [
        {
          "code": "3601667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 2352.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1651.9109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ALEXIS M/L HR105",
      "code_information": [
        {
          "code": "3601692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1076.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5 SHORT 6149.1038S",
      "code_information": [
        {
          "code": "3601700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLEY-COUVEL 3-W",
      "code_information": [
        {
          "code": "3601705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 99.5419,
          "maximum": 216.9843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-O3 OXIMETRY CEREBRAL",
      "code_information": [
        {
          "code": "3601707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM",
      "code_information": [
        {
          "code": "3601709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 929.1887,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1676.5847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM BOX",
      "code_information": [
        {
          "code": "3601710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2537,
          "minimum": 165.7178,
          "maximum": 1841.1009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1564.9358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 23/M P01-900-2303",
      "code_information": [
        {
          "code": "3601722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 4555.0151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1668.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ2 CN P2ND1002",
      "code_information": [
        {
          "code": "3601743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 514.1647,
          "maximum": 1091.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 927.7349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 16FR",
      "code_information": [
        {
          "code": "3601752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 2180.4681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.5081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-DEBRIDEMENT DDBK02",
      "code_information": [
        {
          "code": "3601755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4392.0778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CV/XS 4MM P1-AU551",
      "code_information": [
        {
          "code": "3601759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 2690.4764,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4854.5701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 3/10F AR-98300OBT",
      "code_information": [
        {
          "code": "3601764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 827,
          "minimum": 282.7222,
          "maximum": 600.1539,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.1308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CIR/BEV P45-940-1001",
      "code_information": [
        {
          "code": "3601766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 5151.7104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FLIPCUTTER III AR-1204FF",
      "code_information": [
        {
          "code": "3601777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2543,
          "minimum": 869.3623,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1568.6368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MGS 3MM AR-9628S",
      "code_information": [
        {
          "code": "3601781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.4208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-INFANT NEONATE CO2",
      "code_information": [
        {
          "code": "3601783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.2195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCAN 4MM AR-1204D",
      "code_information": [
        {
          "code": "3601799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1261,
          "minimum": 431.0916,
          "maximum": 1371.8987,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 777.8415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-.066CN 2.75MM AR-7000-14",
      "code_information": [
        {
          "code": "3601800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 1790.3019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1521.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X6\\\" AR-8941-6",
      "code_information": [
        {
          "code": "3601803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X7\\\" AR-8941-7",
      "code_information": [
        {
          "code": "3601804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 923.6821,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG ST TR AR-7823",
      "code_information": [
        {
          "code": "3601805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1024.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JTIP 8164-2001-25",
      "code_information": [
        {
          "code": "3601822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRAY AR-200SP",
      "code_information": [
        {
          "code": "3601873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1980,
          "minimum": 676.8924,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1221.3531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G MIS SHARP 501168",
      "code_information": [
        {
          "code": "3601880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 2801.6318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE 6MM BH-220",
      "code_information": [
        {
          "code": "3601882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11846,
          "minimum": 1735.5881,
          "maximum": 8596.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7307.1459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMAN.157X9\\\" KI71675",
      "code_information": [
        {
          "code": "3601893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 193,
          "minimum": 31.6977,
          "maximum": 140.0601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.0511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .035X9\\\" DD KI71211",
      "code_information": [
        {
          "code": "3601894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 7509.5744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FRACTURE KEX152EB",
      "code_information": [
        {
          "code": "3601895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 13504,
          "minimum": 870.8526,
          "maximum": 9799.8528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8329.8749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-TIB 11X360MM 1822-1136S",
      "code_information": [
        {
          "code": "3601898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5142,
          "minimum": 1757.8691,
          "maximum": 10766.096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3171.817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LASER TRACH #5 102004050",
      "code_information": [
        {
          "code": "3601900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1245,
          "minimum": 425.6218,
          "maximum": 1157.2441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 767.972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-BLOOD COLLECT 04258",
      "code_information": [
        {
          "code": "3601933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 424.5345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 360.8543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77720",
      "code_information": [
        {
          "code": "3601934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 744,
          "minimum": 254.3475,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 458.9327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .062X5\\\" 5050-249",
      "code_information": [
        {
          "code": "3601939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 143,
          "minimum": 48.8867,
          "maximum": 103.7751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.2088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLUTION-WOUND VASHE 16OZ 003",
      "code_information": [
        {
          "code": "3601945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 24996.1389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 192.4556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX944",
      "code_information": [
        {
          "code": "3601947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 278,
          "minimum": 95.0384,
          "maximum": 7214.8414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM AO 702473",
      "code_information": [
        {
          "code": "3601950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2131,
          "minimum": 728.514,
          "maximum": 1546.4667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1314.4967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-7MM P20-910-7000",
      "code_information": [
        {
          "code": "3601961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 1746.7101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1062.8239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 400MM BT 693.060S",
      "code_information": [
        {
          "code": "3601978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 525,
          "minimum": 179.4791,
          "maximum": 1399.7037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 323.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM 1032-115-000",
      "code_information": [
        {
          "code": "3601985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10370,
          "minimum": 3545.1386,
          "maximum": 11179.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6396.6826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM 2PROBE 9700-020-200",
      "code_information": [
        {
          "code": "3601986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 20104,
          "minimum": 265.8158,
          "maximum": 14589.4728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 12401.0519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-AEOS STERILE PV012SU",
      "code_information": [
        {
          "code": "3601989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 462,
          "minimum": 157.9416,
          "maximum": 335.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 284.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA 22FR 77422",
      "code_information": [
        {
          "code": "3601990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 191.1025,
          "maximum": 1175.5954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.8164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ENDO 5MM 174209",
      "code_information": [
        {
          "code": "3601996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1819,
          "minimum": 464.8996,
          "maximum": 1320.0483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1122.0411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 6213-119-070",
      "code_information": [
        {
          "code": "3601997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 194.0789,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.6824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PURESOME TMD-07",
      "code_information": [
        {
          "code": "3601998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 349,
          "minimum": 99.5419,
          "maximum": 253.2693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM AR-8943-36",
      "code_information": [
        {
          "code": "3602028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1198,
          "minimum": 409.5541,
          "maximum": 869.3886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 738.9803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PED LUMBAR 21G 645",
      "code_information": [
        {
          "code": "3602032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.0891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN HEEL 10X10",
      "code_information": [
        {
          "code": "3602037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 142.3616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X C/D",
      "code_information": [
        {
          "code": "3602043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X C/D",
      "code_information": [
        {
          "code": "3602044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 209.0016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 177.6514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X C/D",
      "code_information": [
        {
          "code": "3602045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL C/D",
      "code_information": [
        {
          "code": "3602046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG C/D",
      "code_information": [
        {
          "code": "3602047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED C/D",
      "code_information": [
        {
          "code": "3602048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K SMALL C/D",
      "code_information": [
        {
          "code": "3602049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X A/B",
      "code_information": [
        {
          "code": "3602050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X A/B",
      "code_information": [
        {
          "code": "3602051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X A/B",
      "code_information": [
        {
          "code": "3602052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 209.0016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 177.6514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL A/B",
      "code_information": [
        {
          "code": "3602053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG A/B",
      "code_information": [
        {
          "code": "3602054",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN CMP 2.2 DSDS0022",
      "code_information": [
        {
          "code": "3602079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1175.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-JOINT PREP INST 9914PK01",
      "code_information": [
        {
          "code": "3602083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 418.1872,
          "maximum": 1704.6693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1448.9689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP 1.1 NT/SM 58820006",
      "code_information": [
        {
          "code": "3602084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 752,
          "minimum": 257.0824,
          "maximum": 1541.5092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 463.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MICA 2X12MM 57SR0212",
      "code_information": [
        {
          "code": "3602085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2772,
          "minimum": 947.6494,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1709.8943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MICA INST BLADE 57S1MI07",
      "code_information": [
        {
          "code": "3602088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2242,
          "minimum": 766.461,
          "maximum": 1627.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1382.9665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAMPATNCY FGS-0668",
      "code_information": [
        {
          "code": "3602103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRUDI SHAVER TSB4STR",
      "code_information": [
        {
          "code": "3602104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 497.7095,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1966.5019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-BIENAIR AQUACARE 1600617",
      "code_information": [
        {
          "code": "3602106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 145.1421,
          "maximum": 433.2429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-OSTOMY 18665",
      "code_information": [
        {
          "code": "3602109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-CLOSED TUBE 1320-0125S",
      "code_information": [
        {
          "code": "3602113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 959,
          "minimum": 327.8484,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 591.5544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 724G",
      "code_information": [
        {
          "code": "3602121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 52.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0 8756H",
      "code_information": [
        {
          "code": "3602122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 7.7854,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.9834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0   8717H",
      "code_information": [
        {
          "code": "3602124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 71.4498,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.9206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-EVARREST 2x4\\\" EVT5024",
      "code_information": [
        {
          "code": "3602126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4700,
          "minimum": 1606.7648,
          "maximum": 3410.79,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2899.1715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-6 LEAD ECG SNAP BR-916PA",
      "code_information": [
        {
          "code": "3602128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1080,
          "minimum": 369.214,
          "maximum": 783.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 666.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TRI 4.0MM P1-AU411",
      "code_information": [
        {
          "code": "3602153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7067,
          "minimum": 207.4253,
          "maximum": 5128.5219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4359.2436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1076.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.2351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.4208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.2965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 706.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 C012D",
      "code_information": [
        {
          "code": "3602196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 190.7423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.1626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1024.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 3788.7093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2484.6517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1076.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.2351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.4208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.2965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 706.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3164,
          "minimum": 1081.6604,
          "maximum": 2296.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1951.6976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 2923.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2484.6517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1024.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-END +5 HUM 1830-0005S",
      "code_information": [
        {
          "code": "3602288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1128,
          "minimum": 385.6236,
          "maximum": 1795.0908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 695.8012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1076.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.2351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 994.9347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2785,
          "minimum": 952.0936,
          "maximum": 2021.0745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.9133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 706.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT DL 15MM PROBE 9700-015-200",
      "code_information": [
        {
          "code": "3602331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 22350,
          "minimum": 870.8526,
          "maximum": 16219.395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13786.4857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 637.2906,
          "maximum": 2923.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2484.6517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3164,
          "minimum": 1081.6604,
          "maximum": 2296.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1951.6976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2185,
          "minimum": 746.9747,
          "maximum": 5893.5478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1347.8063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2484.6517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1024.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1076.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1010.4337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.2351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.4208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.2965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 706.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT 125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 3017.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5426,
          "minimum": 1854.9587,
          "maximum": 3937.6482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3347.001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2185,
          "minimum": 746.9747,
          "maximum": 3017.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1347.8063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5426,
          "minimum": 580.5684,
          "maximum": 3937.6482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3347.001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 13MM 7786713",
      "code_information": [
        {
          "code": "3602404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 7786703",
      "code_information": [
        {
          "code": "3602405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-MDI SPACER M 1082715",
      "code_information": [
        {
          "code": "3602410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 136.2445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.7687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRXPERION XP65/115VS",
      "code_information": [
        {
          "code": "3602411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 83.7569,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 151.127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH SZ5/90MM A0A14",
      "code_information": [
        {
          "code": "3602422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 2737.1242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON LINEAR 40",
      "code_information": [
        {
          "code": "3602462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5202,
          "minimum": 99.5419,
          "maximum": 3775.0914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3208.8277,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 111331",
      "code_information": [
        {
          "code": "3602483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 966,
          "minimum": 330.2415,
          "maximum": 1123.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 595.8723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SKIN CLOSURE CLR602US",
      "code_information": [
        {
          "code": "3602486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1556,
          "minimum": 531.9417,
          "maximum": 1129.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 959.8108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-RADIAN FACET K 5526061",
      "code_information": [
        {
          "code": "3602487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1514,
          "minimum": 517.5834,
          "maximum": 1098.7098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 933.9033,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 11MM 7786711",
      "code_information": [
        {
          "code": "3602491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PELVIC STAB T-PODR",
      "code_information": [
        {
          "code": "3602497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 319.6436,
          "maximum": 5019.3586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 576.7501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIR-G BL-NOSE 3X900 0101-900S",
      "code_information": [
        {
          "code": "3602503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 981.5165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 772.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165MM S0210-200",
      "code_information": [
        {
          "code": "3602508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1940,
          "minimum": 663.2178,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1196.6793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OPEN REAMER 03.168.004",
      "code_information": [
        {
          "code": "3602515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8067,
          "minimum": 1758.9443,
          "maximum": 5854.2219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4976.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3X413MM 03.168.011",
      "code_information": [
        {
          "code": "3602516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3163,
          "minimum": 1079.9462,
          "maximum": 2295.3891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1951.0807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LOWER 8/+0 END 2330-0000S",
      "code_information": [
        {
          "code": "3602538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1299,
          "minimum": 444.0825,
          "maximum": 942.6843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 801.2817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEART LOOP AV 9S44R",
      "code_information": [
        {
          "code": "3602540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 525,
          "minimum": 179.4791,
          "maximum": 3726.9822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 323.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-LOW PROFILE 6143.2527",
      "code_information": [
        {
          "code": "3602541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6702,
          "minimum": 2249.4245,
          "maximum": 4863.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4134.0952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 160MM P45-180-0160",
      "code_information": [
        {
          "code": "3602542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4045,
          "minimum": 1382.8434,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2495.138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 160MM P45-112-0140",
      "code_information": [
        {
          "code": "3602543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 1091.6243,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4167.4048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-G BALL 3X550 P31-955-1550",
      "code_information": [
        {
          "code": "3602544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1963,
          "minimum": 610.0417,
          "maximum": 1424.5491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1210.8667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-300MM THRED P45-310-0300",
      "code_information": [
        {
          "code": "3602545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 3455.6054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 676.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRUTS-QA MOD MD P45-224-0170",
      "code_information": [
        {
          "code": "3602546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6214,
          "minimum": 870.8526,
          "maximum": 4509.4998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3833.0748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KET-ENDO BSC CEK-924-20",
      "code_information": [
        {
          "code": "3602548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 13697.2991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.7059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INST ARAGONITE MINI-DS",
      "code_information": [
        {
          "code": "3602550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 13194.0286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1242.3258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOINT-BALL MOD P45-233-1000",
      "code_information": [
        {
          "code": "3602557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2049.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE 1.8 P99-202-1810",
      "code_information": [
        {
          "code": "3602569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1065,
          "minimum": 207.4253,
          "maximum": 772.8705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 656.9399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCPP41D",
      "code_information": [
        {
          "code": "3602572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.6489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PRONE LAT STAB 6246.0200",
      "code_information": [
        {
          "code": "3602576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7446,
          "minimum": 2545.5257,
          "maximum": 5403.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4593.0279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TT 2.4X9.25 AR-8870K",
      "code_information": [
        {
          "code": "3602593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 235,
          "minimum": 80.3382,
          "maximum": 900.3259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 144.9586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT W/CAP",
      "code_information": [
        {
          "code": "3602596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT 205-212",
      "code_information": [
        {
          "code": "3602597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT WAVE+ 3.9M",
      "code_information": [
        {
          "code": "3602598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2957.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT FLEX 2.9MM",
      "code_information": [
        {
          "code": "3602599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 1542.8361,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2783.8215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT SMOL 2.9MM",
      "code_information": [
        {
          "code": "3602600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3012,
          "minimum": 870.8526,
          "maximum": 2185.8084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1857.9371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3602604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4897,
          "minimum": 1674.1122,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3020.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3602606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4897,
          "minimum": 1674.1122,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3020.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.2L CN AR-8973-32LS",
      "code_information": [
        {
          "code": "3602614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 4355.9313,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 963.5119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°RT AR-4068-90R",
      "code_information": [
        {
          "code": "3602617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°LT AR-4068-90L",
      "code_information": [
        {
          "code": "3602618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 524.7626,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 946.8571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°LT AR-4068-45L",
      "code_information": [
        {
          "code": "3602619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 524.7626,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 946.8571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°RT AR-4068-45R",
      "code_information": [
        {
          "code": "3602620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 222.9961,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 946.8571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPLEDAM AR-6530TD",
      "code_information": [
        {
          "code": "3602621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 247.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DTRAX SPINAL DX-22-300",
      "code_information": [
        {
          "code": "3602622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 870.8526,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3131.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS 11G/5\\\"\\\" 0306-116-000",
      "code_information": [
        {
          "code": "3602624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 774,
          "minimum": 264.6034,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 477.438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-GUIDE VDR 80-0049",
      "code_information": [
        {
          "code": "3602651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1847.3642,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-OPTIFIX ABSORB 0113126",
      "code_information": [
        {
          "code": "3602652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2049.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 14FR G00996",
      "code_information": [
        {
          "code": "3602678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 12FR G00995",
      "code_information": [
        {
          "code": "3602679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-MWCE-18S-4/2-TORNADO",
      "code_information": [
        {
          "code": "3602685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1086,
          "minimum": 371.2652,
          "maximum": 788.1102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 669.8937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-10-8 MREYE",
      "code_information": [
        {
          "code": "3602686",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-8 MREYE G42423",
      "code_information": [
        {
          "code": "3602687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION MREYE G42414",
      "code_information": [
        {
          "code": "3602690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-5 MREYE G42410",
      "code_information": [
        {
          "code": "3602691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-4 MREYE G42409",
      "code_information": [
        {
          "code": "3602692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-3 MREYE G42408",
      "code_information": [
        {
          "code": "3602693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-2-3 MREYE G42406",
      "code_information": [
        {
          "code": "3602694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 7516.2476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 15MM X 15G",
      "code_information": [
        {
          "code": "3602699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1426,
          "minimum": 487.4993,
          "maximum": 1034.8482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 879.621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CO 2.10MM NS1806.002 STE",
      "code_information": [
        {
          "code": "3602710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1658,
          "minimum": 566.8119,
          "maximum": 5094.4321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1022.729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2883-01-024",
      "code_information": [
        {
          "code": "3602763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1645,
          "minimum": 265.2597,
          "maximum": 1193.7765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1014.71,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC SAW 1.27MM 71440375",
      "code_information": [
        {
          "code": "3602770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 5079.4174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 456.4653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X340MM 1806-4260S",
      "code_information": [
        {
          "code": "3602772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1134,
          "minimum": 387.6748,
          "maximum": 1969.7062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 699.5022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 13X300MM 351.27",
      "code_information": [
        {
          "code": "3602773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3542,
          "minimum": 1210.8853,
          "maximum": 2570.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2184.865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 360.05S",
      "code_information": [
        {
          "code": "3602774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4064,
          "minimum": 522.734,
          "maximum": 2949.2448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2506.8581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 38FR 68138",
      "code_information": [
        {
          "code": "3602784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 462,
          "minimum": 157.9416,
          "maximum": 42159.6093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 284.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/15CM CA1815",
      "code_information": [
        {
          "code": "3602790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 11543.5238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 30FR 68130",
      "code_information": [
        {
          "code": "3602796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 418.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 355.3027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 32FR 68132",
      "code_information": [
        {
          "code": "3602797",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 602,
          "minimum": 205.8026,
          "maximum": 436.8714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.3407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 36FR 68136",
      "code_information": [
        {
          "code": "3602798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 418.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 355.3027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 34FR 68134",
      "code_information": [
        {
          "code": "3602799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR",
      "code_information": [
        {
          "code": "3602805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 436,
          "minimum": 149.0531,
          "maximum": 368.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.9444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94895",
      "code_information": [
        {
          "code": "3602818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 755.4537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 642.1356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94835",
      "code_information": [
        {
          "code": "3602819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 755.4537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 642.1356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3602851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 207.4253,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 787.7111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 16G/15CM CA1615",
      "code_information": [
        {
          "code": "3602858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 14G/11CM CA1411",
      "code_information": [
        {
          "code": "3602859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 553.8756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 X523H",
      "code_information": [
        {
          "code": "3602867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0  X513H",
      "code_information": [
        {
          "code": "3602868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.3286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7 W/QC STD TP 71933035",
      "code_information": [
        {
          "code": "3602893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 1656.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1407.6403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-W/ NEEDLES #0 SUTURE",
      "code_information": [
        {
          "code": "3602933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-EXTREMITIES UNIVERSAL",
      "code_information": [
        {
          "code": "3602935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1194",
      "code_information": [
        {
          "code": "3602936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 4768.0014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 592.788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ201",
      "code_information": [
        {
          "code": "3602938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1157.2126,
          "maximum": 2456.4945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ101",
      "code_information": [
        {
          "code": "3602939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1157.2126,
          "maximum": 2509.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 180MM P45-112-0180",
      "code_information": [
        {
          "code": "3602943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 2249.4245,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4167.4048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 180MM P45-180-0180",
      "code_information": [
        {
          "code": "3602944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4045,
          "minimum": 1382.8434,
          "maximum": 2935.4565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2495.138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-4H THRED P45-921-0004",
      "code_information": [
        {
          "code": "3602945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2618,
          "minimum": 870.8526,
          "maximum": 1899.8826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1614.9002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CALIBRA 4X165MM 0225-000",
      "code_information": [
        {
          "code": "3602953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2376,
          "minimum": 812.2709,
          "maximum": 1922.9938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1465.6237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5MMPINX9.5MMROD 1151-200",
      "code_information": [
        {
          "code": "3602954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3458,
          "minimum": 1182.1687,
          "maximum": 2509.4706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2133.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-9.5 X 9.5MM ROD 1151-200",
      "code_information": [
        {
          "code": "3602955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3458,
          "minimum": 1182.1687,
          "maximum": 2509.4706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2133.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X150MM 1152-150",
      "code_information": [
        {
          "code": "3602956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X200MM 1152-200",
      "code_information": [
        {
          "code": "3602957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X250MM 1152-250",
      "code_information": [
        {
          "code": "3602958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X300 1152-300",
      "code_information": [
        {
          "code": "3602959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 3591.2938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN ASSEM 1158-000",
      "code_information": [
        {
          "code": "3602960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6458,
          "minimum": 1377.4597,
          "maximum": 4686.5706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3983.585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VENASEAL CLOSURE VS-404",
      "code_information": [
        {
          "code": "3602966",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1687.4449,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3044.7469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-5.5 P20-910-5500",
      "code_information": [
        {
          "code": "3602974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 1250.3811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1062.8239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK -.5 P20-915-5500",
      "code_information": [
        {
          "code": "3602976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 4037.8421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1062.8239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PROTECT 5.0 P45-198-5000",
      "code_information": [
        {
          "code": "3602978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5320",
      "code_information": [
        {
          "code": "3603015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1167,
          "minimum": 398.9563,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 719.8581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-150MM THRED P45-310-0150",
      "code_information": [
        {
          "code": "3603022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 1522.6018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 420.0714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-CUBE 4H P45-925-0004",
      "code_information": [
        {
          "code": "3603023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2738,
          "minimum": 870.8526,
          "maximum": 1986.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1688.9216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-3/16\\\" SQ P99-000-316P",
      "code_information": [
        {
          "code": "3603028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 199.0838,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 8MM P45-914-0003",
      "code_information": [
        {
          "code": "3603029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 9787.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.8305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ULTRALOOP-HS FIBER 72205445",
      "code_information": [
        {
          "code": "3603051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 531.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM PROBE 9700-020-100",
      "code_information": [
        {
          "code": "3603057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21773,
          "minimum": 1205.6248,
          "maximum": 15800.6661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13430.5662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/F P01-900-1702",
      "code_information": [
        {
          "code": "3603060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 358.6845,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1668.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F40 64611",
      "code_information": [
        {
          "code": "3603068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63306",
      "code_information": [
        {
          "code": "3603069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63305",
      "code_information": [
        {
          "code": "3603070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 149.0348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE SMALL",
      "code_information": [
        {
          "code": "3603071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.3145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE LARGE",
      "code_information": [
        {
          "code": "3603072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.3145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE MEDIUM",
      "code_information": [
        {
          "code": "3603073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 45.6002,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.3145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYNG SZ4 321400000U",
      "code_information": [
        {
          "code": "3603074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 165.7178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL WIDE",
      "code_information": [
        {
          "code": "3603075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.8198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL FITPACK",
      "code_information": [
        {
          "code": "3603076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X400MM 1152-400",
      "code_information": [
        {
          "code": "3603081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 60.0588,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP427H",
      "code_information": [
        {
          "code": "3603082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 2619.7871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOULTION-WOUND VASHE 118ML",
      "code_information": [
        {
          "code": "3603095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 225,
          "minimum": 76.9196,
          "maximum": 176.8398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.7901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ULTRABRAID SZ2 7210915",
      "code_information": [
        {
          "code": "3603096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 35594.2927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.1567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-50 COBLATION 72290037",
      "code_information": [
        {
          "code": "3603101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1887,
          "minimum": 287.5037,
          "maximum": 1369.3959,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1163.9865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3603102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 517,
          "minimum": 176.7441,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 318.9089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-5.5 72202530",
      "code_information": [
        {
          "code": "3603103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 676.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-HRVST SYS SK27",
      "code_information": [
        {
          "code": "3603104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5613,
          "minimum": 1474.2211,
          "maximum": 4073.3541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3462.351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INST-GUIDE RELEASE SN20",
      "code_information": [
        {
          "code": "3603105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 8186.3481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1635.2561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-HK BONE REMOVAL SN25",
      "code_information": [
        {
          "code": "3603107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1635.2561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRIPLE EDGE INST SN21",
      "code_information": [
        {
          "code": "3603108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 110.6639,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1635.2561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0 C013D",
      "code_information": [
        {
          "code": "3603114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 797.4474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.5457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-FILSHIE AVM-851J",
      "code_information": [
        {
          "code": "3603115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1434,
          "minimum": 490.2342,
          "maximum": 8660.1453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 884.5557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERC SUTURE AR-7267",
      "code_information": [
        {
          "code": "3603119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2049.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 14MM 2022-30-014S",
      "code_information": [
        {
          "code": "3603135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 1159.6686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 985.7183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 16MM 2022-30-016S",
      "code_information": [
        {
          "code": "3603136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 1159.6686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 985.7183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PIN PROT WHT 5027-1-040",
      "code_information": [
        {
          "code": "3603139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-DELIVERY STRBL-14F-075",
      "code_information": [
        {
          "code": "3603178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3603179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2957.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3603180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2957.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 8F",
      "code_information": [
        {
          "code": "3603181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2957.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 9F",
      "code_information": [
        {
          "code": "3603182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 51.7173,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2957.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 8MM 022108-10",
      "code_information": [
        {
          "code": "3603183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 712.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TPR 3MM 5407-FA3-030",
      "code_information": [
        {
          "code": "3603184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1282,
          "minimum": 438.2708,
          "maximum": 930.3474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 790.7953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 6MM 5820-010-160",
      "code_information": [
        {
          "code": "3603185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1494,
          "minimum": 510.7461,
          "maximum": 1084.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 921.5664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RASP-HELI 3.2MM 5120-080-030",
      "code_information": [
        {
          "code": "3603186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1446,
          "minimum": 494.3366,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 891.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 7205306",
      "code_information": [
        {
          "code": "3603188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 501.6022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.6645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 1683H",
      "code_information": [
        {
          "code": "3603192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 4507.1905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.6465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3603196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3050,
          "minimum": 178.5081,
          "maximum": 2213.385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1881.3773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT C0R47",
      "code_information": [
        {
          "code": "3603197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS CFF74",
      "code_information": [
        {
          "code": "3603198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 60.0588,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEEDLE WINGED INF WNIS01",
      "code_information": [
        {
          "code": "3603199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 914.2284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED CTF73",
      "code_information": [
        {
          "code": "3603214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANN-VENOUS HI FLO 24FR 69324",
      "code_information": [
        {
          "code": "3603215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 413,
          "minimum": 141.1902,
          "maximum": 4958.7437,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 254.757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A404",
      "code_information": [
        {
          "code": "3603218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 393,
          "minimum": 134.3529,
          "maximum": 364.8016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 242.4201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR 72201513",
      "code_information": [
        {
          "code": "3603219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 656,
          "minimum": 224.2633,
          "maximum": 476.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 404.6503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3603221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 615,
          "minimum": 210.2469,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.3597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SOMFIT 7037-1001-00",
      "code_information": [
        {
          "code": "3603227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 1705.5587,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MOD 12MM 2022-30-012S",
      "code_information": [
        {
          "code": "3603247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 1334.64,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 985.7183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3603277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 35676.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-ZINC OXIDE REMDEY 4OZ",
      "code_information": [
        {
          "code": "3603279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 1897.4132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.2634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT X 2.4/45° 378824",
      "code_information": [
        {
          "code": "3603290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 308,
          "minimum": 101.2102,
          "maximum": 223.5156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 189.9883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-STR SP 15° 378235",
      "code_information": [
        {
          "code": "3603291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 4507.1905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.2658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM BP 0808-115-800",
      "code_information": [
        {
          "code": "3603299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10281,
          "minimum": 1346.3181,
          "maximum": 7460.9217,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6341.7834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-11G VP 0605-411-000",
      "code_information": [
        {
          "code": "3603300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2421,
          "minimum": 827.6548,
          "maximum": 1756.9197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1493.3817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-10G VP 0605-410-000",
      "code_information": [
        {
          "code": "3603301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2421,
          "minimum": 497.7095,
          "maximum": 1756.9197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1493.3817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BL 3X600 AR-9091BK-30S",
      "code_information": [
        {
          "code": "3603303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1635.2561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL 4.2MM AR-9091-42",
      "code_information": [
        {
          "code": "3603304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 26349.6863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1759.8588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CM VP 11G 0306-511-000",
      "code_information": [
        {
          "code": "3603319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 604,
          "minimum": 206.4864,
          "maximum": 2716.5485,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 372.5744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5 REAMING 6143.2571",
      "code_information": [
        {
          "code": "3603340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 5862.9623,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1862.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM F/ANCHOR 72203785",
      "code_information": [
        {
          "code": "3603349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1506,
          "minimum": 514.8485,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 928.9686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X5MM 60-16005",
      "code_information": [
        {
          "code": "3603351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1284,
          "minimum": 438.9545,
          "maximum": 931.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 792.029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X26MM 60-16526",
      "code_information": [
        {
          "code": "3603355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1442,
          "minimum": 492.9691,
          "maximum": 1046.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 889.4905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X35 92-16135",
      "code_information": [
        {
          "code": "3603356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1863,
          "minimum": 480.4704,
          "maximum": 1351.9791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1149.1822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X50/5M 60-15105",
      "code_information": [
        {
          "code": "3603363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1488,
          "minimum": 508.6949,
          "maximum": 1511.4798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 917.8654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X110/20M 60-15620",
      "code_information": [
        {
          "code": "3603364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 726.2666,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1676.5847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13X50/13G NN-2003",
      "code_information": [
        {
          "code": "3603396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 7026.8796,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13222.0726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL DIST 2.8MM 4040-000",
      "code_information": [
        {
          "code": "3603404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1975,
          "minimum": 675.1831,
          "maximum": 6311.1789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1218.2689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 1.5X230MM 0109-230",
      "code_information": [
        {
          "code": "3603406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1380.7963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 706.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE HAND 415S002350",
      "code_information": [
        {
          "code": "3603407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 848.8504,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1531.6261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CIRCUIT NEONATE DUAL LIMB",
      "code_information": [
        {
          "code": "3603429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 754,
          "minimum": 257.7661,
          "maximum": 547.1778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 465.1011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SUCTION TABLE 8Q70R",
      "code_information": [
        {
          "code": "3603430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 633,
          "minimum": 216.4005,
          "maximum": 909.7796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 390.4629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5X150 CN P41-910-5015",
      "code_information": [
        {
          "code": "3603431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1009.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AO CONN P65-001-0001-SK",
      "code_information": [
        {
          "code": "3603438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 6996.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-QUAD TIP 2762-01-0003",
      "code_information": [
        {
          "code": "3603444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 1078.5836,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1946.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2.5CM M00510880",
      "code_information": [
        {
          "code": "3603498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1056.0386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2CM M00510870",
      "code_information": [
        {
          "code": "3603499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 3296.0047,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1056.0386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GENERATOR-RF PROC RLVRFGPR",
      "code_information": [
        {
          "code": "3603504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 14704.3962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1138.6959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ADD ACCESS INST RLV0075",
      "code_information": [
        {
          "code": "3603508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 11091.9706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2435.9209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ACCESS INSTRUMENT RLV0045",
      "code_information": [
        {
          "code": "3603510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9838,
          "minimum": 3363.2665,
          "maximum": 7139.4366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6068.5211,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DAVINCI INSUFF TUBE 470551",
      "code_information": [
        {
          "code": "3603512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1264,
          "minimum": 432.1172,
          "maximum": 3249.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 779.6921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/10CM NN-8006",
      "code_information": [
        {
          "code": "3603527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 16702,
          "minimum": 1866.2716,
          "maximum": 12120.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 10302.5452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X60/13G NN-2004",
      "code_information": [
        {
          "code": "3603530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 632.2857,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13222.0726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 40X11 SM-4011M",
      "code_information": [
        {
          "code": "3603538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 3296.0047,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ALLOGRAFT-22.5MM ABS-4057D-225",
      "code_information": [
        {
          "code": "3603542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5686,
          "minimum": 1943.8436,
          "maximum": 4126.3302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3507.3807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL-1.5x48MM 03.130.212",
      "code_information": [
        {
          "code": "3603544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 124.0103,
          "maximum": 751.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP76",
      "code_information": [
        {
          "code": "3603545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 137.5564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE 9X102 HTOE 05-306",
      "code_information": [
        {
          "code": "3603547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 285.9258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 243.0369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.35X150 AR-8943-01S",
      "code_information": [
        {
          "code": "3603548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.8198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLECTOR-SPECIMEN NN-9002",
      "code_information": [
        {
          "code": "3603569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 700,
          "minimum": 239.3054,
          "maximum": 793.5547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.7915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/13CM NN-8007",
      "code_information": [
        {
          "code": "3603587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 18660,
          "minimum": 6379.1983,
          "maximum": 13541.562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 11510.3277,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X95/13G NN-2006",
      "code_information": [
        {
          "code": "3603588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 7327.8733,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13222.0726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X75/13G NN-2005",
      "code_information": [
        {
          "code": "3603589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 62.8393,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13222.0726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-MYRID NICO NN-9001",
      "code_information": [
        {
          "code": "3603590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 551.6512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 7FRX65C",
      "code_information": [
        {
          "code": "3603592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1624,
          "minimum": 555.1885,
          "maximum": 1178.5368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1001.7563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 5FRX50C",
      "code_information": [
        {
          "code": "3603593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1624,
          "minimum": 555.1885,
          "maximum": 1178.5368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1001.7563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 9FRX65C",
      "code_information": [
        {
          "code": "3603594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1882,
          "minimum": 643.3897,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1160.9023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-20-22FR/45CM G52835",
      "code_information": [
        {
          "code": "3603768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1759,
          "minimum": 601.3403,
          "maximum": 1276.5063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1085.0304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16-18FR/45CM G52834",
      "code_information": [
        {
          "code": "3603769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1759,
          "minimum": 601.3403,
          "maximum": 2381.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1085.0304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-32-35MM 102024003",
      "code_information": [
        {
          "code": "3603771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 2465.7474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1635.2561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.4X27 ST 60-14126",
      "code_information": [
        {
          "code": "3603794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 3325.478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 685.9316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOWN-WARMING BEAR PAW 81001",
      "code_information": [
        {
          "code": "3603809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 6791.0932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPYSCOPE DS II M00546610",
      "code_information": [
        {
          "code": "3603810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12212,
          "minimum": 1866.2716,
          "maximum": 8862.2484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7532.9111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-EHL 1.9F 375CM M00546620",
      "code_information": [
        {
          "code": "3603814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2879,
          "minimum": 984.2289,
          "maximum": 2089.2903,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1775.8968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONEMILL MD 5420-MED-000",
      "code_information": [
        {
          "code": "3603815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3354,
          "minimum": 1146.6147,
          "maximum": 5094.4321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2068.8981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CRV DIAMOND 15° 1600650",
      "code_information": [
        {
          "code": "3603818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CYLINDER 60° 1600578",
      "code_information": [
        {
          "code": "3603819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X200MM P99-192-1620",
      "code_information": [
        {
          "code": "3603836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 6.6732,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2.0 3846T",
      "code_information": [
        {
          "code": "3603837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 8.7084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7.4021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 7-0 Z135H",
      "code_information": [
        {
          "code": "3603876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 273,
          "minimum": 93.3291,
          "maximum": 9887.458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.3987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 45X6 SM-4506",
      "code_information": [
        {
          "code": "3603888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 8750.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-38MM ARS743201",
      "code_information": [
        {
          "code": "3603895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 969.0635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-14X127MM ARS743303",
      "code_information": [
        {
          "code": "3603897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 1140.0747,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 969.0635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE .9MM 57S90005",
      "code_information": [
        {
          "code": "3603901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 468.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 397.865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM MXM-072-19",
      "code_information": [
        {
          "code": "3603904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1109.7042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-76/3 ARS743202",
      "code_information": [
        {
          "code": "3603910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 969.0635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 8.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.6786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603923",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.6786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.6786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 6.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 49.4929,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.6786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SM CHLD NR34015813",
      "code_information": [
        {
          "code": "3603926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.8992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015814",
      "code_information": [
        {
          "code": "3603927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.8992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PRO-FLOW NR37000145",
      "code_information": [
        {
          "code": "3603928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMETRY EM951160CP",
      "code_information": [
        {
          "code": "3603931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 41.7075,
          "maximum": 148.0428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.8364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ADULT NR34015818",
      "code_information": [
        {
          "code": "3603932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 54.4275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.2634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASALNR354S5011",
      "code_information": [
        {
          "code": "3603933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 45.6002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015816",
      "code_information": [
        {
          "code": "3603934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 72.8491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.5813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG WEBB NR104B1420",
      "code_information": [
        {
          "code": "3603935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 131,
          "minimum": 44.7843,
          "maximum": 294.1769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.8067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-EEG 8OZ NR10200005",
      "code_information": [
        {
          "code": "3603936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 529,
          "minimum": 87.8638,
          "maximum": 383.8953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 326.311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUPREP-4OZ TUBE NR10210004",
      "code_information": [
        {
          "code": "3603937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 32.8099,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.4615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THERMOCAN NR34015808",
      "code_information": [
        {
          "code": "3603938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 17894.7419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR/6.7MM 80220",
      "code_information": [
        {
          "code": "3603955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 238.719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CLEARVUE LARYNG #3",
      "code_information": [
        {
          "code": "3603957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.2195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NOMOLINE LH NASAL/ORAL",
      "code_information": [
        {
          "code": "3603958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 150.9456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.3038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 22FR BE2050",
      "code_information": [
        {
          "code": "3603960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 864.3087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 734.6624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LITHOTRIPER PROBE 3.9MM",
      "code_information": [
        {
          "code": "3603972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4400,
          "minimum": 1504.2054,
          "maximum": 3193.08,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2714.118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T-15 TORQUE 702750",
      "code_information": [
        {
          "code": "3603979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3611,
          "minimum": 1234.474,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2227.4273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIMITER-TORQUE 2.5NM 702760",
      "code_information": [
        {
          "code": "3603985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4015,
          "minimum": 1372.5874,
          "maximum": 4387.0729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2476.6327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/15 STPL THN00482",
      "code_information": [
        {
          "code": "3603988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2099,
          "minimum": 717.5743,
          "maximum": 1523.2443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1294.7577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/20 STPL THN00483",
      "code_information": [
        {
          "code": "3603989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2099,
          "minimum": 717.5743,
          "maximum": 1523.2443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1294.7577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA 22.5FR 7275",
      "code_information": [
        {
          "code": "3604022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM*CLEARIFY 21-345",
      "code_information": [
        {
          "code": "3604025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 CHROMIC GUT 792G",
      "code_information": [
        {
          "code": "3604027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 85.4662,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 154.2113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-NANO 29.5X7MM SM-3115",
      "code_information": [
        {
          "code": "3604043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-MET 20MM MPN20120",
      "code_information": [
        {
          "code": "3604048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2049.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHAL 20MM MPN20020",
      "code_information": [
        {
          "code": "3604049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 667.8761,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2049.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM SHT MSTD1030",
      "code_information": [
        {
          "code": "3604050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE DUAL 844023S",
      "code_information": [
        {
          "code": "3604137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 291,
          "minimum": 71.1808,
          "maximum": 211.1787,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 179.5019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 2X200 MSG20200",
      "code_information": [
        {
          "code": "3604156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 1511.4798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.6 F/5.5MM MSN10013",
      "code_information": [
        {
          "code": "3604157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 667.8761,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1676.5847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM LNG MSTD0030",
      "code_information": [
        {
          "code": "3604158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 2274.449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA-G GENERATION 2",
      "code_information": [
        {
          "code": "3604162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10740,
          "minimum": 3671.6286,
          "maximum": 7794.018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6624.9153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-STAPLE SZ THN00292",
      "code_information": [
        {
          "code": "3604165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1242.3258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 5.0MM 3100-01-0005",
      "code_information": [
        {
          "code": "3604167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 795.7791,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.7487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 2.4MM 2900-04-0229",
      "code_information": [
        {
          "code": "3604168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1431,
          "minimum": 489.2086,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 882.7052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-6.5MM 3100-01-0007",
      "code_information": [
        {
          "code": "3604169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 1147.6403,
          "maximum": 8783.5995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.7487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-7X90 3200-01-7090",
      "code_information": [
        {
          "code": "3604170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 15795,
          "minimum": 5399.7555,
          "maximum": 11462.4315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 9743.0668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SONATA DE-001-10",
      "code_information": [
        {
          "code": "3604172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 877,
          "minimum": 278.05,
          "maximum": 636.4389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 540.9731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS BONE BX 0306-115-000",
      "code_information": [
        {
          "code": "3604196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 798,
          "minimum": 272.8082,
          "maximum": 4376.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 492.2423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-DSG XS 2.5MM P1-AU514",
      "code_information": [
        {
          "code": "3604197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 551.6512,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4854.5701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DISTRACTOR 12MM 02.600.022",
      "code_information": [
        {
          "code": "3604198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 611.9102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-#0/8\\\"\\\" GREEN VLOCA008L",
      "code_information": [
        {
          "code": "3604209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1317,
          "minimum": 450.236,
          "maximum": 955.7469,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.3849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX977",
      "code_information": [
        {
          "code": "3604217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 507.7193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.3904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ACESSA 7300",
      "code_information": [
        {
          "code": "3604227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14892,
          "minimum": 265.8158,
          "maximum": 10807.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 9186.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-HEAD SILVERMAN SZ F",
      "code_information": [
        {
          "code": "3604228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X12MM AR-300-B003",
      "code_information": [
        {
          "code": "3604244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 1790.3019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1521.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUT 2 P41-960-0020",
      "code_information": [
        {
          "code": "3604263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 1250.3811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1062.8239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5.5X150 CN P41-910-5515",
      "code_information": [
        {
          "code": "3604264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1187.2452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1009.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X150 CN P41-910-4015",
      "code_information": [
        {
          "code": "3604265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1187.2452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1009.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-GPS LONG 6143.2515",
      "code_information": [
        {
          "code": "3604278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6702,
          "minimum": 836.3744,
          "maximum": 4863.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4134.0952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 8.0",
      "code_information": [
        {
          "code": "3604284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 7.5",
      "code_information": [
        {
          "code": "3604285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED",
      "code_information": [
        {
          "code": "3604286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER TRACH PORTEX 100",
      "code_information": [
        {
          "code": "3604287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 51.7173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEMALE TO FEMALE",
      "code_information": [
        {
          "code": "3604289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 1322.9619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-1.8MM PERK AR-3610PK-3",
      "code_information": [
        {
          "code": "3604294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1586,
          "minimum": 542.1977,
          "maximum": 1763.3931,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 978.3162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SR8 GEMINI AR-6572",
      "code_information": [
        {
          "code": "3604301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 3149.1943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 247.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLSRE SKN 22CM EF70401",
      "code_information": [
        {
          "code": "3604305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 711,
          "minimum": 243.0659,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 438.5768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH 14 1/4\\\" 020116801",
      "code_information": [
        {
          "code": "3604307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 804.9827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-TISSUE HIGH EX71010",
      "code_information": [
        {
          "code": "3604311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-WIRE FIX XL 76-10104",
      "code_information": [
        {
          "code": "3604319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1375,
          "minimum": 470.0642,
          "maximum": 997.8375,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 848.1619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR PEDIATRIC S-1003",
      "code_information": [
        {
          "code": "3604329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 264,
          "minimum": 90.2523,
          "maximum": 5757.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 162.8471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT SHORT 71-6130S",
      "code_information": [
        {
          "code": "3604330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10354,
          "minimum": 870.8526,
          "maximum": 7513.8978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6386.8131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 4H 76-10140",
      "code_information": [
        {
          "code": "3604333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1043.7017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 2H 76-10125",
      "code_information": [
        {
          "code": "3604334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1043.7017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 200MM 76-11200",
      "code_information": [
        {
          "code": "3604335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1151,
          "minimum": 207.4253,
          "maximum": 835.2807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 709.9886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 115MM 76-11115",
      "code_information": [
        {
          "code": "3604337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 934,
          "minimum": 319.3018,
          "maximum": 3255.4094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 576.1332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FH 4.2MM AR-9091F-42",
      "code_information": [
        {
          "code": "3604351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1759.8588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CON 4.3X13MM AR-300-B101",
      "code_information": [
        {
          "code": "3604352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2470,
          "minimum": 7.7854,
          "maximum": 1792.479,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1523.6072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE SKIN EF70466",
      "code_information": [
        {
          "code": "3604355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 933,
          "minimum": 101.7663,
          "maximum": 677.0781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 575.5164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEN-ADHESIVE EP70412",
      "code_information": [
        {
          "code": "3604356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.8826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACTIVALVE-PROVOX STRONG 7161",
      "code_information": [
        {
          "code": "3604357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 662.3151,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2435.9209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET ACCESS INST LV3 RLV0055",
      "code_information": [
        {
          "code": "3604369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12997,
          "minimum": 3490.6397,
          "maximum": 9431.9229,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8017.1345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.6X200 AR-5050K-1",
      "code_information": [
        {
          "code": "3604376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM RC P01-DWL-0915",
      "code_information": [
        {
          "code": "3604386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-FOGARTY DSOFT33",
      "code_information": [
        {
          "code": "3604398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-DRAIN/FLUSH LL AFA-LL",
      "code_information": [
        {
          "code": "3604403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #4",
      "code_information": [
        {
          "code": "3604406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 294.6342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 250.4391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-6 THD/10 HEX 76-10180",
      "code_information": [
        {
          "code": "3604415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 235,
          "minimum": 80.3382,
          "maximum": 175.1715,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 144.9586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-FLANGE 10HX 76-10182",
      "code_information": [
        {
          "code": "3604416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 3503.9861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.3062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD +3OS/25MM MWJ007",
      "code_information": [
        {
          "code": "3604423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5858,
          "minimum": 580.5684,
          "maximum": 4251.1506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3613.478,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODEL-REV BONE MWJ015",
      "code_information": [
        {
          "code": "3604424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 14259.5162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.0 A-3938",
      "code_information": [
        {
          "code": "3604432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2061,
          "minimum": 506.051,
          "maximum": 1495.6677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1271.3175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 16FR 26-016",
      "code_information": [
        {
          "code": "3604433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 660.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 561.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 12FR 26-012",
      "code_information": [
        {
          "code": "3604434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 660.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 561.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 18FR 26-018",
      "code_information": [
        {
          "code": "3604435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 561.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-6X150 CN P41-910-6015",
      "code_information": [
        {
          "code": "3604457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1009.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CAL 5.5MM S0288-200",
      "code_information": [
        {
          "code": "3604470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2470,
          "minimum": 844.4062,
          "maximum": 3563.4888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1523.6072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.6MM TRC AR-18700-71",
      "code_information": [
        {
          "code": "3604479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 638.9589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO",
      "code_information": [
        {
          "code": "3604489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 686,
          "minimum": 71.1808,
          "maximum": 497.8302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 423.1557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1069210",
      "code_information": [
        {
          "code": "3604490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 4015.5981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-HO 7/1.6X80 P99-205-1608",
      "code_information": [
        {
          "code": "3604512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1065,
          "minimum": 364.0861,
          "maximum": 877.5258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 656.9399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GRAFT SIZING AR-1676ST",
      "code_information": [
        {
          "code": "3604518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 8964.332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.4208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMANN .157X9\\\"\\\" KI71615",
      "code_information": [
        {
          "code": "3604550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.5185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL SP-78105",
      "code_information": [
        {
          "code": "3604567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1274,
          "minimum": 435.5358,
          "maximum": 924.5418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 785.8605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 1MM 5820-013-010",
      "code_information": [
        {
          "code": "3604568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 427.6409,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 787.7111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 12X18/2 DS24",
      "code_information": [
        {
          "code": "3604569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 769,
          "minimum": 262.8941,
          "maximum": 558.0633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 474.3538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/0 DS26",
      "code_information": [
        {
          "code": "3604570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 832,
          "minimum": 284.4316,
          "maximum": 603.7824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 513.215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 29/37 TF2937O",
      "code_information": [
        {
          "code": "3604581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 376.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-AMPLATZ 8F M0062601010",
      "code_information": [
        {
          "code": "3604584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 481,
          "minimum": 164.437,
          "maximum": 349.0617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.7024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEM 19F/6.3 96570-119",
      "code_information": [
        {
          "code": "3604596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2245,
          "minimum": 767.4866,
          "maximum": 1629.1965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1384.817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 19F/6.3MM 96530-119",
      "code_information": [
        {
          "code": "3604597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 848.8504,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1531.6261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 21F/7MM 96530-121",
      "code_information": [
        {
          "code": "3604598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 134.0201,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1531.6261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WHITE 15X12MM DLP-W11",
      "code_information": [
        {
          "code": "3604599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.6596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-YELLOW 15X12MM DLP-S11",
      "code_information": [
        {
          "code": "3604600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.6596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-11MM 261222",
      "code_information": [
        {
          "code": "3604605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 1943.4246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1651.9109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 650-750CC SZHP68650",
      "code_information": [
        {
          "code": "3604611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 550-640CC SZHP68550",
      "code_information": [
        {
          "code": "3604612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 425-455CC SZHP68425",
      "code_information": [
        {
          "code": "3604613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 320-340CC SZHP68320",
      "code_information": [
        {
          "code": "3604614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 549,
          "minimum": 187.6838,
          "maximum": 398.4093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 338.6479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 200-260CC SZHP68200",
      "code_information": [
        {
          "code": "3604615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 750-800CC SZHP68750",
      "code_information": [
        {
          "code": "3604616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 577.6572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 491.0086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 2MM 5820-010-120",
      "code_information": [
        {
          "code": "3604621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 3MM 5820-010-130",
      "code_information": [
        {
          "code": "3604622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 4MM 5820-010-140",
      "code_information": [
        {
          "code": "3604623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 3MM 5820-012-030",
      "code_information": [
        {
          "code": "3604624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 436.5614,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 787.7111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 4MM 5820-012-040",
      "code_information": [
        {
          "code": "3604625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1494,
          "minimum": 510.7461,
          "maximum": 1084.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 921.5664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 3 5820-013-030",
      "code_information": [
        {
          "code": "3604626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 4 5820-013-040",
      "code_information": [
        {
          "code": "3604627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 841.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SAHARA S-1150-08LF",
      "code_information": [
        {
          "code": "3604628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1182,
          "minimum": 37.8148,
          "maximum": 857.7774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 729.1108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 20FR 123120",
      "code_information": [
        {
          "code": "3604629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12X150MM FE CFF71",
      "code_information": [
        {
          "code": "3604631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X150MM FE CFF01",
      "code_information": [
        {
          "code": "3604632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X100MM BLADE CFB03",
      "code_information": [
        {
          "code": "3604633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 47.2685,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 9MM 022109-10",
      "code_information": [
        {
          "code": "3604634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 61.6845,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.4318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 10MM 022110-10",
      "code_information": [
        {
          "code": "3604635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 12MM 022112-10",
      "code_information": [
        {
          "code": "3604636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 14MM 022114-10",
      "code_information": [
        {
          "code": "3604637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 16MM 022116-10",
      "code_information": [
        {
          "code": "3604638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGAMAX 5MM CLIP EL5ML",
      "code_information": [
        {
          "code": "3000771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1389,
          "minimum": 474.8503,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 856.7977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380EM",
      "code_information": [
        {
          "code": "3003259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 1089.8652,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1966.5019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-I-STAT CREATININE",
      "code_information": [
        {
          "code": "3004750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.4318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 22FR 30CC      266722",
      "code_information": [
        {
          "code": "3004837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.7118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 289.3003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CORONARY PERF    30055",
      "code_information": [
        {
          "code": "3010039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE LITE 30-403LITE",
      "code_information": [
        {
          "code": "3010311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3419,
          "minimum": 1168.836,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2108.9931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN TWIST 2.7MM W/AO F",
      "code_information": [
        {
          "code": "3012109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2077,
          "minimum": 710.0533,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1281.1871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.0MM ASNIS",
      "code_information": [
        {
          "code": "3012113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1913,
          "minimum": 653.9875,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1180.0245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP NICU HNICU37",
      "code_information": [
        {
          "code": "3019903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z463G",
      "code_information": [
        {
          "code": "3032618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3058698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 919,
          "minimum": 314.1738,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 566.8806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPINPERC INS-5600",
      "code_information": [
        {
          "code": "3058755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2207,
          "minimum": 754.4957,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1361.3769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE 1.5X36",
      "code_information": [
        {
          "code": "3058775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.6824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 CX ALL",
      "code_information": [
        {
          "code": "3058846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2609.8712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PED 900PT531",
      "code_information": [
        {
          "code": "3059068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 722,
          "minimum": 246.8264,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.3621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-ABSOLUTE PSI-TEC",
      "code_information": [
        {
          "code": "3059124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 211.5778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LIGASURE SM  LF1212A",
      "code_information": [
        {
          "code": "3059951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3010,
          "minimum": 1029.0132,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1856.7034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-LEVER EDGE    4100-01",
      "code_information": [
        {
          "code": "3059965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1454,
          "minimum": 497.0715,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 896.8926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST-OP XL MALE      1315",
      "code_information": [
        {
          "code": "3079661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL HEALTHVENT 24HR 97021",
      "code_information": [
        {
          "code": "3081122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.7711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-GLOW AND TELL     1100-20",
      "code_information": [
        {
          "code": "3083225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 191.1025,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.8164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN CUFF 7.0MM",
      "code_information": [
        {
          "code": "3085522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.2433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM   70890830",
      "code_information": [
        {
          "code": "3526275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.0487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL EPISTAX 10CM",
      "code_information": [
        {
          "code": "3526349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 289.3003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRING-MR EMPOWERCTA",
      "code_information": [
        {
          "code": "3526487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR GYN DYNJ60136",
      "code_information": [
        {
          "code": "3527022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 190.7606,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.1995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MOMOPTY 20X15 21201",
      "code_information": [
        {
          "code": "3549005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 458,
          "minimum": 156.5741,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 282.515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-LAT VEIN WORLEY",
      "code_information": [
        {
          "code": "3549219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2264,
          "minimum": 773.982,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1396.5371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-PCL 2.4MMX10",
      "code_information": [
        {
          "code": "3549231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Y-PORT-20 FR M00580641",
      "code_information": [
        {
          "code": "3549284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOAM-BUMP 10X6X6\\\" DYNJBUMP03",
      "code_information": [
        {
          "code": "3549293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 99.312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-0xx-000",
      "code_information": [
        {
          "code": "3549839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CEMENT MIX 0206-015-000",
      "code_information": [
        {
          "code": "3549999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 192.8118,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.9006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-INTERLOCKING 3MMX4CM M001",
      "code_information": [
        {
          "code": "3550029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2529,
          "minimum": 864.5762,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1560.001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-W/F L&L PED ALL 5002s",
      "code_information": [
        {
          "code": "3550092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-BRILL 3.5 682.108S",
      "code_information": [
        {
          "code": "3550131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP 180-210CC",
      "code_information": [
        {
          "code": "3550332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL",
      "code_information": [
        {
          "code": "3550461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 613.1439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STEM 2862-02-204",
      "code_information": [
        {
          "code": "3550481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1448.9689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT LARGE YG-282T",
      "code_information": [
        {
          "code": "3550639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.8174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 0200-20",
      "code_information": [
        {
          "code": "3550659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 473.141,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.7135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-BONE 3.8X13CM AR-8380BC",
      "code_information": [
        {
          "code": "3550684",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 486.0739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110MM 213524",
      "code_information": [
        {
          "code": "3550809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 582.9185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CLEARCUT 5X13 AR-8500COS",
      "code_information": [
        {
          "code": "3550848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 486.0739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND 2.5MM 1882569HS",
      "code_information": [
        {
          "code": "3559015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1938,
          "minimum": 662.5341,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1195.4456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FEMALE EXT PWF-030K",
      "code_information": [
        {
          "code": "3559082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.2931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LAMINARIA-#4 MED 60MM 021004",
      "code_information": [
        {
          "code": "3559244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT OPEN EB240",
      "code_information": [
        {
          "code": "3559437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1407.6403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X56MM 03.130.202",
      "code_information": [
        {
          "code": "3559456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV",
      "code_information": [
        {
          "code": "3559628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWRIST 2.5MM 60-25326",
      "code_information": [
        {
          "code": "3559663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 685.9316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARDS-NEONATAL NOISE NON-MAG",
      "code_information": [
        {
          "code": "3598028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 215,
          "minimum": 73.5009,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 132.6217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-MULTIPURPOSE TUBING",
      "code_information": [
        {
          "code": "3598219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.9016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUB LIPO 3-TT-FILTRON",
      "code_information": [
        {
          "code": "3598384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2403,
          "minimum": 821.5013,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1482.2785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW 25CM NSLX125C",
      "code_information": [
        {
          "code": "3598495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2676,
          "minimum": 914.8304,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1650.6772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN",
      "code_information": [
        {
          "code": "3598509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1055,
          "minimum": 360.6674,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 650.7715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3598587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.6824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND HANZ RT LG",
      "code_information": [
        {
          "code": "3599041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 494,
          "minimum": 168.8812,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.7214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ATERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 157.2955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-SELF LOCKING 4933-0-802",
      "code_information": [
        {
          "code": "3600214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.9669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-6MM/SD PARA 108843106",
      "code_information": [
        {
          "code": "3600452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2435.9209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-EAR DISP 4015",
      "code_information": [
        {
          "code": "3600557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.2872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CADD PCA 108” 21-7391-24",
      "code_information": [
        {
          "code": "3600723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT FEEDINGTUBE G3561",
      "code_information": [
        {
          "code": "3600751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 478.6717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-LF",
      "code_information": [
        {
          "code": "3600788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1799.9537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 10' 251010J",
      "code_information": [
        {
          "code": "3600900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.0072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-SUCT&ANTICOAG BT275",
      "code_information": [
        {
          "code": "3601009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.9016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS BIPOLAR 2MM",
      "code_information": [
        {
          "code": "3601053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1667,
          "minimum": 569.8887,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1028.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-100-4630",
      "code_information": [
        {
          "code": "3601111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1726.5492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-HEAD 17.5 03.404.031S",
      "code_information": [
        {
          "code": "3601120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3893,
          "minimum": 1330.8799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2401.3776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLUE STAPLE GCR40B",
      "code_information": [
        {
          "code": "3601345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1903,
          "minimum": 650.5688,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1173.856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47520",
      "code_information": [
        {
          "code": "3601391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 772.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 11X100MM 4922-8-100",
      "code_information": [
        {
          "code": "3601641",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1743,
          "minimum": 595.8705,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1075.1608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.0MM",
      "code_information": [
        {
          "code": "3601769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.2824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE",
      "code_information": [
        {
          "code": "3602129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 798.8143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 25MM X 15G",
      "code_information": [
        {
          "code": "3602700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1426,
          "minimum": 487.4993,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 879.621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCRW-POST+NUT SET B0223000",
      "code_information": [
        {
          "code": "3603037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1552.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOWS-SOLO FITPACK SLP1SMSLA",
      "code_information": [
        {
          "code": "3603077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.8257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREADED CTF03",
      "code_information": [
        {
          "code": "3603177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGATION P65-001-0006-SK",
      "code_information": [
        {
          "code": "3603437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1316,
          "minimum": 449.8942,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 811.768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE SINGLE 800099S",
      "code_information": [
        {
          "code": "3604138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATE STD 20MM M0056183",
      "code_information": [
        {
          "code": "3604224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 297,
          "minimum": 101.5339,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 3.1X20MM AR-300-B202",
      "code_information": [
        {
          "code": "3604247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1521.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM C P01-901-0901-S",
      "code_information": [
        {
          "code": "3604385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1668.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET SCREW T7 5560010000",
      "code_information": [
        {
          "code": "3604395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 301.8667,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 544.6741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #3",
      "code_information": [
        {
          "code": "3604407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 250.4391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-COAXIAL BIPSY 946x-VC-006",
      "code_information": [
        {
          "code": "1416380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 154.5958,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OPTIFIX-ABSORBABLE 0113126",
      "code_information": [
        {
          "code": "3000012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1095.517,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 7.3     310.495",
      "code_information": [
        {
          "code": "3002265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT LARYNGEAL 4MM",
      "code_information": [
        {
          "code": "3003289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 431.5336,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OXFORD SAW 506298",
      "code_information": [
        {
          "code": "3003294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 432.0897,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-TUR PK           786500",
      "code_information": [
        {
          "code": "3003816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 710.1397,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 96370-023",
      "code_information": [
        {
          "code": "3004233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 988.1897,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-020",
      "code_information": [
        {
          "code": "3008516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 11X280       357.404",
      "code_information": [
        {
          "code": "3012311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2482.4304,
          "payers_information": [
            {
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX     2274-25-500",
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        },
        {
          "code": "0270",
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        {
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              "methodology": "percent of total billed charges",
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            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 7.0X3.2",
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          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
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      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-HALO CUTTING HACF-0533",
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          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 870.8526,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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    {
      "description": "KIT-EVICEL FIBRIN SEALANT 3905",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
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              "methodology": "percent of total billed charges",
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            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-SEALER 5MM     LF1637",
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      "standard_charges": [
        {
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          "minimum": 1147.2985,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "LOOP-TUR       784415 & 784515",
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        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
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        {
          "code": "0270",
          "type": "RC"
        }
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      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      ],
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    },
    {
      "description": "NEEDLE-NAVIGATED PAK9733498NAV",
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          "code": "0270",
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        }
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      "standard_charges": [
        {
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          "minimum": 398.1676,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-OPEN HEART     DYNJ32033A",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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            {
              "payer_name": "Anthem",
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "PROBE-ULTRASOUND ALL SZ 840-7s",
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS EPIDUR VEIN",
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        {
          "code": "0270",
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        }
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DEEP SCROTAL RETRACTION",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 564.9976,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS1",
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          "code": "3083596",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 265.8158,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VERSAJET II 66800041",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1147.2985,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPEICE VERSAJET II 66800042",
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        {
          "code": "3091506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 45\\\" HARH45",
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          "code": "3091507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-HEMOPERFUSION SKN602",
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        {
          "code": "3506295",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 018 XFR004118",
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        {
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          "type": "RC"
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      ],
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 018 XFR004218",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-ANCHORAGE CP XFR006100",
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        },
        {
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        }
      ],
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-MARYLAND OPEN LF1937",
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        },
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          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-ABIOMED .018\\\" 0052-3005",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ITEM-STRAIGHT 5450800307",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1147.2985,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-UNIV SONIC 5450815114",
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        {
          "code": "3527001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-VENTRIC PACING    D98100",
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        {
          "code": "3533572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 107.8834,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.915S",
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        {
          "code": "3547954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-7.0 CANNULATED 400146",
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        {
          "code": "3549092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSSEPTAL RF",
      "code_information": [
        {
          "code": "3549157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER A-2816",
      "code_information": [
        {
          "code": "3549230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 762.4131,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 10MM 03.037.021",
      "code_information": [
        {
          "code": "3549749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 550 AC-10030120",
      "code_information": [
        {
          "code": "3549756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 563.3293,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRING 675.705S",
      "code_information": [
        {
          "code": "3550106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-8\\\" INSULATED 675.706S",
      "code_information": [
        {
          "code": "3550107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIPOLAR 675.170S",
      "code_information": [
        {
          "code": "3550116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 698.605S",
      "code_information": [
        {
          "code": "3550117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 17566.6429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER/SHAVER-ALL",
      "code_information": [
        {
          "code": "3550238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HAMMER-SLAP 694.008",
      "code_information": [
        {
          "code": "3550243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 7877.7126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-DIRECT MEASURE 702495",
      "code_information": [
        {
          "code": "3550617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 207.4253,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-HELIX 6.5 ADVANCE 222313",
      "code_information": [
        {
          "code": "3550751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.7X160 A-8004.01",
      "code_information": [
        {
          "code": "3550825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 207.4253,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DRIVER 4 CANN A-8004.11",
      "code_information": [
        {
          "code": "3550827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1146.6782,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-LIGASURE 37CM LF1944",
      "code_information": [
        {
          "code": "3559070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 16MM XFR004216",
      "code_information": [
        {
          "code": "3559091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 6524.7213,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-WIRELESS CELL EX1151",
      "code_information": [
        {
          "code": "3559233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-15MM/3.5OS 9159.3035",
      "code_information": [
        {
          "code": "3559597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 2.0",
      "code_information": [
        {
          "code": "3559670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 134.5762,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3566817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 689.564,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40B GCS40B",
      "code_information": [
        {
          "code": "3598106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM 03.333.103",
      "code_information": [
        {
          "code": "3598147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 875.3014,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-STRT TIP BAYON 1590-01",
      "code_information": [
        {
          "code": "3598218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 108.9956,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH",
      "code_information": [
        {
          "code": "3598452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SUREFORM 60 480460",
      "code_information": [
        {
          "code": "3598611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 27CM APYX-27-TP",
      "code_information": [
        {
          "code": "3598956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 491.0363,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-1X10.5MM BI 632.678S",
      "code_information": [
        {
          "code": "3599051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERCLAGE AR-7268",
      "code_information": [
        {
          "code": "3599170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-CERCLAGE AR-7268T",
      "code_information": [
        {
          "code": "3599171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1128.883,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM 03.333.102",
      "code_information": [
        {
          "code": "3599533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 716.2568,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-NANO 125MM AR-3210-0043",
      "code_information": [
        {
          "code": "3600299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 667.8761,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-MINI COREDX M00515220",
      "code_information": [
        {
          "code": "3600762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3531.235,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR CVD GCS40G",
      "code_information": [
        {
          "code": "3600838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2679.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-LARGE DV2012-LF",
      "code_information": [
        {
          "code": "3600953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-8-13MM P99-110-0813",
      "code_information": [
        {
          "code": "3601104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-UNIVERSAL PAD ARTICGEL",
      "code_information": [
        {
          "code": "3601634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 4183.5403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIBER OPTIC PTEYE-1",
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        {
          "code": "3602127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 600.588,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2848.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE 45\\\" HAR745",
      "code_information": [
        {
          "code": "3602909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE HAR736",
      "code_information": [
        {
          "code": "3602910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 149.5909,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA 13CM PRE1101US",
      "code_information": [
        {
          "code": "3603187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 253.0255,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 11G NN-1000",
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        {
          "code": "3603528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 13G NN-1001",
      "code_information": [
        {
          "code": "3603586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 10376.826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY MAX M00546470",
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        {
          "code": "3603811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL M00546550",
      "code_information": [
        {
          "code": "3603812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-RETRIEVAL M00546560",
      "code_information": [
        {
          "code": "3603813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-8MM/CV SF30 488530",
      "code_information": [
        {
          "code": "3603862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY 115CM G48240",
      "code_information": [
        {
          "code": "3603969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3975.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 25 LS96555-025",
      "code_information": [
        {
          "code": "3604574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SUPERLOOP TUR 784415",
      "code_information": [
        {
          "code": "3604601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2070.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1411090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-20      G00810",
      "code_information": [
        {
          "code": "1414825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOFILTER-ASP FLTR",
      "code_information": [
        {
          "code": "3002210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 508,
          "minimum": 173.6673,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 313.3573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR",
      "code_information": [
        {
          "code": "3002324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM        388.394",
      "code_information": [
        {
          "code": "3002383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         60-20385",
      "code_information": [
        {
          "code": "3002391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1102,
          "minimum": 376.7351,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 679.7632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD DISP   8000-140",
      "code_information": [
        {
          "code": "3003251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.2575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-COLON CYTO        000110",
      "code_information": [
        {
          "code": "3003503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 99.312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND S03.000.009S",
      "code_information": [
        {
          "code": "3003841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 333.0963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO SMALL  1320-3042S",
      "code_information": [
        {
          "code": "3012204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1181,
          "minimum": 403.7424,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 728.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM       60-19326",
      "code_information": [
        {
          "code": "3012208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 685.9316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0           310.21",
      "code_information": [
        {
          "code": "3012318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 599.5733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          310.288",
      "code_information": [
        {
          "code": "3012331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 638.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2           405883",
      "code_information": [
        {
          "code": "3012341",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1098,
          "minimum": 375.3676,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.2958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDISPEC        SE-1",
      "code_information": [
        {
          "code": "3012590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 549,
          "minimum": 187.6838,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 338.6479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RJ4 LC BIOPSY 160CM",
      "code_information": [
        {
          "code": "3013323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.8909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0MM 702460",
      "code_information": [
        {
          "code": "3016131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDETHREAD 150MM  292.72",
      "code_information": [
        {
          "code": "3016158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 461,
          "minimum": 157.5997,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 284.3655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CRESCENT         74-1010",
      "code_information": [
        {
          "code": "3021150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 121,
          "minimum": 41.3656,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE LF 022701",
      "code_information": [
        {
          "code": "3029356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 713,
          "minimum": 243.7496,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 439.8105,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PIGTAIL 28-0174",
      "code_information": [
        {
          "code": "3034526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1065,
          "minimum": 364.0861,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 656.9399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LAPAROSCOPIC 5MM  160655",
      "code_information": [
        {
          "code": "3034572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1151,
          "minimum": 393.4865,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 709.9886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM BLUE         XR60B",
      "code_information": [
        {
          "code": "3039920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 514,
          "minimum": 175.7185,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 317.0583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD UNIV     050602",
      "code_information": [
        {
          "code": "3040461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 306,
          "minimum": 104.6106,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 188.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCISSORS-ENDODUT METZ     3142",
      "code_information": [
        {
          "code": "3044930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 460,
          "minimum": 157.2578,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 283.7487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY ALL 351-3000'sS",
      "code_information": [
        {
          "code": "3049750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 ORBIT 7205323",
      "code_information": [
        {
          "code": "3058626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 637,
          "minimum": 217.7679,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 392.9303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I KNIFE SURG 8065921552",
      "code_information": [
        {
          "code": "3058653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN LITE FUD023",
      "code_information": [
        {
          "code": "3058869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-HEEL PRESSURE MDT825",
      "code_information": [
        {
          "code": "3059240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.3359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION LARGE",
      "code_information": [
        {
          "code": "3059275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 272,
          "minimum": 92.9872,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.7818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SWANSON SUTURE  11-0675",
      "code_information": [
        {
          "code": "3060151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 611.9102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-RETRACTO 12\\\" 1041",
      "code_information": [
        {
          "code": "3060247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH      SZ5  A0A04",
      "code_information": [
        {
          "code": "3060306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.9965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-4.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3079259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.6931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-VACURRETTE 5MM       21664",
      "code_information": [
        {
          "code": "3083764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.1329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-TUNNELING            1112",
      "code_information": [
        {
          "code": "3084399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 525,
          "minimum": 179.4791,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 323.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INFLATION   03.804.413S",
      "code_information": [
        {
          "code": "3084946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.7549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12X100MM     H12LP",
      "code_information": [
        {
          "code": "3085208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 702,
          "minimum": 239.9891,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 433.0252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SPIKE INFILTRATION",
      "code_information": [
        {
          "code": "3085534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.6489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX 116230",
      "code_information": [
        {
          "code": "3085546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 321.353,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 579.8343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM PROX",
      "code_information": [
        {
          "code": "3085796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 231.1006,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 416.9872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM VAS          XR30V",
      "code_information": [
        {
          "code": "3086955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 443,
          "minimum": 151.4461,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 273.2623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.8MM        292.68",
      "code_information": [
        {
          "code": "3091218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 623,
          "minimum": 212.9818,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 384.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT COLUMN 470341",
      "code_information": [
        {
          "code": "3115590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.9503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SYRINGE SSS-STP-SP",
      "code_information": [
        {
          "code": "3500008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-LARYNGOSCOPE DISP",
      "code_information": [
        {
          "code": "3518940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POLYLOOP-LIGATING DEVICE HX-40",
      "code_information": [
        {
          "code": "3526123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 966,
          "minimum": 330.2415,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 595.8723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BASIC BREAST DYNJ60139",
      "code_information": [
        {
          "code": "3526420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1180,
          "minimum": 403.4005,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 727.8771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR HEAD/NECK",
      "code_information": [
        {
          "code": "3526670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 377,
          "minimum": 128.8831,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.5506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SUCTION 12.7 HI CAPACITY",
      "code_information": [
        {
          "code": "3527060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.9455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-BIOPSY MARQUEE",
      "code_information": [
        {
          "code": "3527097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 266.3127,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 480.5223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-ACOUSTIC RESPIRATION",
      "code_information": [
        {
          "code": "3541329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 337,
          "minimum": 115.2085,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 207.8768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION OSTOMY BX 1500H",
      "code_information": [
        {
          "code": "3542454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ1",
      "code_information": [
        {
          "code": "3548009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 121,
          "minimum": 41.3656,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KCLAB2C",
      "code_information": [
        {
          "code": "3549038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.8826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-BASIC HEEL PRESSURE",
      "code_information": [
        {
          "code": "3549107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 337,
          "minimum": 115.2085,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 207.8768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULAIDE-CPAP SIZE 2, CA102-",
      "code_information": [
        {
          "code": "3549182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 166,
          "minimum": 56.7496,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.3963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HUMIDIFIER ATSVII BE-1010",
      "code_information": [
        {
          "code": "3549307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5M SHORT 6149.1037",
      "code_information": [
        {
          "code": "3549352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD BK-IS 109185",
      "code_information": [
        {
          "code": "3549411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE HINGED DONJOY",
      "code_information": [
        {
          "code": "3549781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 872,
          "minimum": 298.1062,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 537.8888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL SINGLE PK 1",
      "code_information": [
        {
          "code": "3549805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 611.9102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.6X30 SPEED 703894",
      "code_information": [
        {
          "code": "3550046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 937,
          "minimum": 320.3274,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 577.9838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST ALL SIZE 9105-00s",
      "code_information": [
        {
          "code": "3550085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.0677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X25MM 7005-3325",
      "code_information": [
        {
          "code": "3550159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STATLOCK-URO FOLEY FOL0105",
      "code_information": [
        {
          "code": "3550423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER",
      "code_information": [
        {
          "code": "3550432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 397.865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153207",
      "code_information": [
        {
          "code": "3550599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXYTYKE INFNT W/7’ TUBING",
      "code_information": [
        {
          "code": "3550754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.0297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0X150MM 705234",
      "code_information": [
        {
          "code": "3550888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 903,
          "minimum": 308.704,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4.5MM 080-453",
      "code_information": [
        {
          "code": "3559003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.9313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPREADER-SILIPOS GEL TOE MED",
      "code_information": [
        {
          "code": "3559185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 116239",
      "code_information": [
        {
          "code": "3559543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1039,
          "minimum": 355.1976,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 640.902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-DRESSING CHANGE 4D",
      "code_information": [
        {
          "code": "3571200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.4995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE RCM-14815",
      "code_information": [
        {
          "code": "3598048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 839,
          "minimum": 286.8246,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 517.533,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-REINFUSION SB1E",
      "code_information": [
        {
          "code": "3598227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 191.8388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-Z-FLO FLUID",
      "code_information": [
        {
          "code": "3598273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 441,
          "minimum": 150.7624,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 272.0286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 22GX.75\\\"",
      "code_information": [
        {
          "code": "3598320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHEST-DRAIN 4050-100N",
      "code_information": [
        {
          "code": "3598393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 294.2351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION SZ:8",
      "code_information": [
        {
          "code": "3598398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 211.5778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISTAL DUODENOVIDEOSCOPE",
      "code_information": [
        {
          "code": "3598674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Suture-7-0 Prolene Blue 8704H",
      "code_information": [
        {
          "code": "3598759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR PAPERELLA 510-043C",
      "code_information": [
        {
          "code": "3598871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.7059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X3.5MM AR-8741-14",
      "code_information": [
        {
          "code": "3600715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 375.6586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-12\\\" THD AR-8967KT-12",
      "code_information": [
        {
          "code": "3601044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.9337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CHEST VENT HYFIN TWINPACK",
      "code_information": [
        {
          "code": "3601126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 150MM 4933-1-150",
      "code_information": [
        {
          "code": "3601246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 527,
          "minimum": 180.1628,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 325.0773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC LARGE 313-9015W",
      "code_information": [
        {
          "code": "3601352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-3X7 AR-9300DS",
      "code_information": [
        {
          "code": "3601434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 827,
          "minimum": 282.7222,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.1308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON PEG ENFIT",
      "code_information": [
        {
          "code": "3601438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN 2.55MM MD 45303155",
      "code_information": [
        {
          "code": "3601456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TROCH 1.35MM AR-8737-02",
      "code_information": [
        {
          "code": "3601814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .045X5\\\" 5050-248",
      "code_information": [
        {
          "code": "3601940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXT-PERCUTANEOUS 9009",
      "code_information": [
        {
          "code": "3601976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED A/B",
      "code_information": [
        {
          "code": "3602055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-ORGO IRRIGATION 1502152",
      "code_information": [
        {
          "code": "3602107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.9965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HAWKINS 18GX15CM G05045",
      "code_information": [
        {
          "code": "3602657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.4415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X250 AO 1806-8018S",
      "code_information": [
        {
          "code": "3602902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1150,
          "minimum": 393.1446,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 709.3718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.35MM AR-5050-01",
      "code_information": [
        {
          "code": "3603040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOVIE-E-Z CLEAN 0014A",
      "code_information": [
        {
          "code": "3603224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.2634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 VICRYL PLUS VCP762D",
      "code_information": [
        {
          "code": "3603378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 132.0048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.9X27MM 60-19126",
      "code_information": [
        {
          "code": "3603820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 685.9316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y415H",
      "code_information": [
        {
          "code": "3603838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7.4021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE 1.4MM 57S90004",
      "code_information": [
        {
          "code": "3603902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 397.865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SPO2 ADULT NR37004030",
      "code_information": [
        {
          "code": "3603929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 18FR BE6050",
      "code_information": [
        {
          "code": "3603961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 734.6624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CIRCUMCISION 1.45CM",
      "code_information": [
        {
          "code": "3604060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 605,
          "minimum": 206.8282,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 373.1912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VICRYL VCP104G",
      "code_information": [
        {
          "code": "3604215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.6952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MINITAPE-LOOPED 72205435",
      "code_information": [
        {
          "code": "3604218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 913,
          "minimum": 312.1226,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.1795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 6X7 AR-6535TD",
      "code_information": [
        {
          "code": "3604297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 247.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7/F 2.4 AR-8916-18",
      "code_information": [
        {
          "code": "3604317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-NYLON 11MM/265ML CD005",
      "code_information": [
        {
          "code": "3604438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/2 DS28",
      "code_information": [
        {
          "code": "3604571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 815,
          "minimum": 278.6199,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 502.7287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-33MM LF EVERGRIP33",
      "code_information": [
        {
          "code": "3604594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 359,
          "minimum": 122.7295,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 221.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE    16G X 12.5",
      "code_information": [
        {
          "code": "1410723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 103.9907,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM         310.44",
      "code_information": [
        {
          "code": "3002798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 25.5806,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 125ML 04251",
      "code_information": [
        {
          "code": "3003421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 285.2793,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPORT II PAL-406LS",
      "code_information": [
        {
          "code": "3004250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 3.2X300MM",
      "code_information": [
        {
          "code": "3014238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 124.5664,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE  2839-xx-xxx",
      "code_information": [
        {
          "code": "3027302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 268.0402,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-TRIMANO BEACH CHAIR",
      "code_information": [
        {
          "code": "3034325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 11 G06732",
      "code_information": [
        {
          "code": "3059264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-4.5MM INCISOR PLUS",
      "code_information": [
        {
          "code": "3060481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30BL      TX30B",
      "code_information": [
        {
          "code": "3081557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 50.6051,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER   60-6085-20x",
      "code_information": [
        {
          "code": "3145100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3521005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 143.4738,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSDUCER TRUWAVE PX272",
      "code_information": [
        {
          "code": "3526526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 99.5419,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLOWSAFE II",
      "code_information": [
        {
          "code": "3549715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 56.7222,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-TRANSFUSION EXCHANGE",
      "code_information": [
        {
          "code": "3571501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 210.2058,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR CARE XL MULTI-USE",
      "code_information": [
        {
          "code": "3598079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/SHOULDER WRAP",
      "code_information": [
        {
          "code": "3598181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 10ML GIS-59",
      "code_information": [
        {
          "code": "3599411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 265.8158,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPAP BUBBLE MR290 CHAMBER",
      "code_information": [
        {
          "code": "3599616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 162.9373,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G ACCESS 03.804.517S",
      "code_information": [
        {
          "code": "3600911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 153.4836,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300S NTHRD 702463S",
      "code_information": [
        {
          "code": "3602409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 58.3905,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL",
      "code_information": [
        {
          "code": "3602464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 231.8937,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANTENNA-PROGRAMMER       37092",
      "code_information": [
        {
          "code": "3000651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        310.111",
      "code_information": [
        {
          "code": "3002241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2       AR-8944-22",
      "code_information": [
        {
          "code": "3002251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0          316.396",
      "code_information": [
        {
          "code": "3002271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1875.7253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM         310.31",
      "code_information": [
        {
          "code": "3002300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 913.1162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM         310.11",
      "code_information": [
        {
          "code": "3002784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2767.1536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM         310.26",
      "code_information": [
        {
          "code": "3002788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DISSECT ELECTRODE 139330",
      "code_information": [
        {
          "code": "3002955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW             511.9xxS",
      "code_information": [
        {
          "code": "3003266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS  03.000.3xxS",
      "code_information": [
        {
          "code": "3003268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 532.066S",
      "code_information": [
        {
          "code": "3003293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 225 ML04253",
      "code_information": [
        {
          "code": "3003420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 4MM PAL-404LLB",
      "code_information": [
        {
          "code": "3004044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-304LLB",
      "code_information": [
        {
          "code": "3004046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO PAL-304LM",
      "code_information": [
        {
          "code": "3004053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 5832.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHOLANGIOGRAM       C100",
      "code_information": [
        {
          "code": "3005220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR TITANIUM  FV012T",
      "code_information": [
        {
          "code": "3009771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3          316.402",
      "code_information": [
        {
          "code": "3012305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM AR-4160-35",
      "code_information": [
        {
          "code": "3012347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.141",
      "code_information": [
        {
          "code": "3012354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 310.25",
      "code_information": [
        {
          "code": "3012405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 926.4626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-558",
      "code_information": [
        {
          "code": "3012475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1960.8086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUGE 03.804.5x",
      "code_information": [
        {
          "code": "3020805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PREP     546102000",
      "code_information": [
        {
          "code": "3020926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 654.5297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 24FR      880-213",
      "code_information": [
        {
          "code": "3021819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE WATER",
      "code_information": [
        {
          "code": "3023171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTROSURG 134006",
      "code_information": [
        {
          "code": "3029511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL  1.5MM W/8.0MM STOP",
      "code_information": [
        {
          "code": "3058520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM CALIBRATED",
      "code_information": [
        {
          "code": "3058937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 12013.4283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 19 G05880",
      "code_information": [
        {
          "code": "3058996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 4706.8304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8943-",
      "code_information": [
        {
          "code": "3059000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 949.2627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-AIRWAY EXCH 8F G07833",
      "code_information": [
        {
          "code": "3059157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 5MM          CB5LT",
      "code_information": [
        {
          "code": "3079768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DOYLE II AIRWY 15-24055",
      "code_information": [
        {
          "code": "3080045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-                TLC-55",
      "code_information": [
        {
          "code": "3081528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30GRN     TX30G",
      "code_information": [
        {
          "code": "3081555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-8916-14",
      "code_information": [
        {
          "code": "3087940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CALIBRATED DRILL 2.5",
      "code_information": [
        {
          "code": "3087942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER     G3640x",
      "code_information": [
        {
          "code": "3509540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BACK TABLE     DYNJ31777A",
      "code_information": [
        {
          "code": "3526152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VASCULAR LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3526426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE UNTHREAD 2X200MM",
      "code_information": [
        {
          "code": "3526988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 16/18 FR 96551",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 664.5395,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 305.969,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SOMA ADULT SAFB-SM/USA",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8426.0272,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DELIVERY NAVIFLEX 7FR.",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EPG CONNECTOR 53912D",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-NAIL 1806-1406S",
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        {
          "code": "3549850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1038.2387,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VORTRAN RESUSCITATION",
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        {
          "code": "3550702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2020-00-335",
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        {
          "code": "3550711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 11041.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-DRILLING COMP EL-DTS",
      "code_information": [
        {
          "code": "3550764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1293.4886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SPEED FEMORAL AE-1605",
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        {
          "code": "3550845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SELECTOR-VEIN 57538CSV-WOR",
      "code_information": [
        {
          "code": "3559121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2416.2545,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-INSTRUMENT 0306-531-000",
      "code_information": [
        {
          "code": "3559266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 37149.7044,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-EXCELSIUS ARM 6143.2001S",
      "code_information": [
        {
          "code": "3559497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-MONITOR 6143.2003S",
      "code_information": [
        {
          "code": "3559498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/KNEE WRAP",
      "code_information": [
        {
          "code": "3598180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 94725",
      "code_information": [
        {
          "code": "3598197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE MIXTURE",
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        {
          "code": "3598303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1194.5028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTYCORE 16GX7.5CM",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELBOW TRIMANO AR-1646",
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        {
          "code": "3598377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN 1.7/2.0 DRILL 45-20011",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.1X150MM 03.333.001",
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        {
          "code": "3599532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.5X150MM QC 03.133.109",
      "code_information": [
        {
          "code": "3599727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-90° SAG 2296-003-109S2",
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        {
          "code": "3599964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 16H 76-9103",
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        {
          "code": "3600836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 24H 76-9104",
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        {
          "code": "3600837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB NTHRD AR-18800-11",
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        {
          "code": "3600896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 305.969,
          "maximum": 8315.3633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE STER 03.804.519S",
      "code_information": [
        {
          "code": "3600903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X330 S0100-000",
      "code_information": [
        {
          "code": "3601632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 749.0667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FISTULA FUNNEL",
      "code_information": [
        {
          "code": "3601648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2901.7298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE BVT 03.804.520S",
      "code_information": [
        {
          "code": "3601878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8783.5995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE RUNTHRU 180 25-5211",
      "code_information": [
        {
          "code": "3601952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 15224.3497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE ARTERIAL ART356",
      "code_information": [
        {
          "code": "3602029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION PD-IT",
      "code_information": [
        {
          "code": "3602078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OIL-BIENAIR LUBRIFLUID 1600064",
      "code_information": [
        {
          "code": "3602105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE 16G X 16.5",
      "code_information": [
        {
          "code": "3602125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2613.67,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 914.2284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREDED AR-18800-11T",
      "code_information": [
        {
          "code": "3602495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-5 MREYE G36405",
      "code_information": [
        {
          "code": "3602688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-3 MREYE G42419",
      "code_information": [
        {
          "code": "3602689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3602820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 3189.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G BVL 0306-331-000",
      "code_information": [
        {
          "code": "3603302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1474.2211,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE -.9MM AR-7524C",
      "code_information": [
        {
          "code": "3604464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 980.4043,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DBL 4X30/10 PAL-405LL",
      "code_information": [
        {
          "code": "3604617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-8x30/8 PAL-402LL",
      "code_information": [
        {
          "code": "3604619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 552.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 J305H",
      "code_information": [
        {
          "code": "3012910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 27745.4973,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL3-0 27\\\" FS-2",
      "code_information": [
        {
          "code": "3033304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 45.6002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-ETHICON         PCP-20",
      "code_information": [
        {
          "code": "3033960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 831.3695,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUT-PDS 2-0 Z317H",
      "code_information": [
        {
          "code": "3059073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 2682.0703,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VIC 2-0           J317H",
      "code_information": [
        {
          "code": "3088957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J329H",
      "code_information": [
        {
          "code": "3088960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 101.2102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y215H",
      "code_information": [
        {
          "code": "3088973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y214H",
      "code_information": [
        {
          "code": "3088974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-RETENTION 450G",
      "code_information": [
        {
          "code": "3088984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 36\\\"        Z346H",
      "code_information": [
        {
          "code": "3088987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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          ]
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    },
    {
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        }
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        {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "0270",
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        {
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
      "description": "SUTURE-MONOCRYL 0        Y346H",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL  0         J946G",
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        {
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      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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      ],
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          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL 0          J270H",
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        {
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            }
          ]
        }
      ],
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    {
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        {
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      ],
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        {
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          ]
        }
      ],
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    },
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      ],
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        {
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          ]
        }
      ],
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    },
    {
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        },
        {
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      ],
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        {
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          ]
        }
      ],
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    },
    {
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        {
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      ],
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          ]
        }
      ],
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    },
    {
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        {
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      ],
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          ]
        }
      ],
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    },
    {
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        },
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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          ]
        }
      ],
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    },
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        }
      ],
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            }
          ]
        }
      ],
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    },
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        {
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        }
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          ]
        }
      ],
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    },
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          ]
        }
      ],
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    },
    {
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        }
      ],
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          ]
        }
      ],
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    },
    {
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          "code": "0270",
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        }
      ],
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        {
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          ]
        }
      ],
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    },
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          ]
        }
      ],
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    },
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          ]
        }
      ],
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    },
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      ],
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          ]
        }
      ],
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    },
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        {
          "code": "0270",
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      ],
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-SILK 0            A186H",
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        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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          ]
        }
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    },
    {
      "description": "SUTURE-SILK 2-0           623H",
      "code_information": [
        {
          "code": "3089176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 31.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A184H",
      "code_information": [
        {
          "code": "3089178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3089183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A305H",
      "code_information": [
        {
          "code": "3089185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A185H",
      "code_information": [
        {
          "code": "3089186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K831H",
      "code_information": [
        {
          "code": "3089193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 46.7124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0           684H",
      "code_information": [
        {
          "code": "3089198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          A183H",
      "code_information": [
        {
          "code": "3089200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 65.6198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        636H",
      "code_information": [
        {
          "code": "3089205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X964H",
      "code_information": [
        {
          "code": "3089208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 39.4831,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2        X519H",
      "code_information": [
        {
          "code": "3089213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X518H",
      "code_information": [
        {
          "code": "3089214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0       1674H",
      "code_information": [
        {
          "code": "3089236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 37.8148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1673H",
      "code_information": [
        {
          "code": "3089242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 37.2587,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        627H",
      "code_information": [
        {
          "code": "3089245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z339H",
      "code_information": [
        {
          "code": "3089255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 36.1465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0   Z304H",
      "code_information": [
        {
          "code": "3089260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J442H",
      "code_information": [
        {
          "code": "3089274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 1689H",
      "code_information": [
        {
          "code": "3089276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            SA87G",
      "code_information": [
        {
          "code": "3089277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2          J880T",
      "code_information": [
        {
          "code": "3089278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2          460T",
      "code_information": [
        {
          "code": "3089298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J214H",
      "code_information": [
        {
          "code": "3089329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 144.0299,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J662H",
      "code_information": [
        {
          "code": "3089339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J347H",
      "code_information": [
        {
          "code": "3089347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 106.7712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J335H",
      "code_information": [
        {
          "code": "3089359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X425H",
      "code_information": [
        {
          "code": "3089385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 205.757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z333H",
      "code_information": [
        {
          "code": "3089395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 131.2396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 626H",
      "code_information": [
        {
          "code": "3089409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685H",
      "code_information": [
        {
          "code": "3500610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 166.2739,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    684G",
      "code_information": [
        {
          "code": "3500770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 88.4199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          K872H",
      "code_information": [
        {
          "code": "3501015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 18FR 30CC      266718",
      "code_information": [
        {
          "code": "3507735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 42.8197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 0 PDP340H",
      "code_information": [
        {
          "code": "3526247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 5380.8236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-3-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 42.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-3-0 PLUS",
      "code_information": [
        {
          "code": "3526254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 1 PDP341H",
      "code_information": [
        {
          "code": "3549733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 1474.2211,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 4-0 R633H",
      "code_information": [
        {
          "code": "3549987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 2490.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        635G",
      "code_information": [
        {
          "code": "3555389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           622-H",
      "code_information": [
        {
          "code": "3557329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK O             624H",
      "code_information": [
        {
          "code": "3557386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            K834H",
      "code_information": [
        {
          "code": "3557388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           661-G",
      "code_information": [
        {
          "code": "3557535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           662-G",
      "code_information": [
        {
          "code": "3557568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           663-H",
      "code_information": [
        {
          "code": "3557592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 2.0        664G",
      "code_information": [
        {
          "code": "3557990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON            801H",
      "code_information": [
        {
          "code": "3558467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 47.8246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 3-0        1671-H",
      "code_information": [
        {
          "code": "3559001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 580.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         B-842-H",
      "code_information": [
        {
          "code": "3560064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH CHROMIC 3-0 G-122-H",
      "code_information": [
        {
          "code": "3560211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J219H",
      "code_information": [
        {
          "code": "3560487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J258H",
      "code_information": [
        {
          "code": "3560490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-259-H",
      "code_information": [
        {
          "code": "3560505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL          J-416-H",
      "code_information": [
        {
          "code": "3560745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 46.1563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J415H",
      "code_information": [
        {
          "code": "3560840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 32.8099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J417H",
      "code_information": [
        {
          "code": "3561410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        669H",
      "code_information": [
        {
          "code": "3561418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 3-0  J-944-H",
      "code_information": [
        {
          "code": "3561419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-832-H",
      "code_information": [
        {
          "code": "3561461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-833-H",
      "code_information": [
        {
          "code": "3561495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 37.8148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH MONOCRL 2-0   Y259H",
      "code_information": [
        {
          "code": "3562109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 51.1612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3.0    Y-338-H",
      "code_information": [
        {
          "code": "3562123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y416H",
      "code_information": [
        {
          "code": "3562126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0     H822H",
      "code_information": [
        {
          "code": "3562128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 55.0539,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 FS-1    1629H",
      "code_information": [
        {
          "code": "3562140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 22.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8683G",
      "code_information": [
        {
          "code": "3562227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 47.8246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           683G",
      "code_information": [
        {
          "code": "3562240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K871H",
      "code_information": [
        {
          "code": "3562245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 71.1808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP316H",
      "code_information": [
        {
          "code": "3598241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP945G",
      "code_information": [
        {
          "code": "3598400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 J422H",
      "code_information": [
        {
          "code": "3598401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL SZ 1 36\\\" J519H",
      "code_information": [
        {
          "code": "3598406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS #1 VCP371H",
      "code_information": [
        {
          "code": "3598411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 58.9466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 G181H",
      "code_information": [
        {
          "code": "3598414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1670H",
      "code_information": [
        {
          "code": "3598421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 2-0 VCP195H",
      "code_information": [
        {
          "code": "3598422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ #1 VCP569H",
      "code_information": [
        {
          "code": "3598423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 4.0 VCP310H",
      "code_information": [
        {
          "code": "3598433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 32.2538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0 664H",
      "code_information": [
        {
          "code": "3598435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 J306H",
      "code_information": [
        {
          "code": "3598715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 4768.0014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP311H",
      "code_information": [
        {
          "code": "3602123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 116.2249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 663G",
      "code_information": [
        {
          "code": "3602506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 2-0 MCP345H",
      "code_information": [
        {
          "code": "3602920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 4266.3992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0   Y303H",
      "code_information": [
        {
          "code": "3603113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 90.6443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 VCP602H",
      "code_information": [
        {
          "code": "3603514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP305H",
      "code_information": [
        {
          "code": "3604136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 161.8251,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP422H",
      "code_information": [
        {
          "code": "3604226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 8281.4412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP218H",
      "code_information": [
        {
          "code": "3604353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 5822.367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 4-0 VCP434H",
      "code_information": [
        {
          "code": "3604548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 199.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-TOUHY BORST W/SIDE ARM",
      "code_information": [
        {
          "code": "1410050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1049.3607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-FEMORAL ANGIO  DYNJP4119",
      "code_information": [
        {
          "code": "1410800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1343.5376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18GX10CM   G01559",
      "code_information": [
        {
          "code": "1410916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-15      G03955",
      "code_information": [
        {
          "code": "1410919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CLOSED NEEDLE  LNGC-2022",
      "code_information": [
        {
          "code": "1495266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 9G EVIVA",
      "code_information": [
        {
          "code": "1495267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SWIVEL PORTEX 625191",
      "code_information": [
        {
          "code": "3002219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT ANT- 1012S",
      "code_information": [
        {
          "code": "3004017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-RANEY SCALP ADULT 20-1037",
      "code_information": [
        {
          "code": "3008833",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 6374.5743,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE       PMI-TC-SG",
      "code_information": [
        {
          "code": "3010072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 306.4111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE FUZZY       FZ624",
      "code_information": [
        {
          "code": "3020107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 4593.9421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LID-COLLECTION DISP    BKC-506",
      "code_information": [
        {
          "code": "3021629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2446.84,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SURGISAFE ABSORB WHITE",
      "code_information": [
        {
          "code": "3029216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-UNIVRSL I AURO DYNJP1050A",
      "code_information": [
        {
          "code": "3029269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 153.4836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 10CM    70890856",
      "code_information": [
        {
          "code": "3029291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-STENT 6FR M0061802011",
      "code_information": [
        {
          "code": "3038668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR MANIFOLD",
      "code_information": [
        {
          "code": "3050023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 5790.1132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 CX21D",
      "code_information": [
        {
          "code": "3058821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1791.7542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TRU               2C4041",
      "code_information": [
        {
          "code": "3079241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1851.2569,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COAG SUCTION      050-005",
      "code_information": [
        {
          "code": "3085551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ELECTROSURGICAL 8\\\"050-010",
      "code_information": [
        {
          "code": "3085595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 860.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX OUTFLOW AQL-111",
      "code_information": [
        {
          "code": "3086104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-3/8\\\"X3/32\\\"X8'     3508S",
      "code_information": [
        {
          "code": "3086137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 CX22D",
      "code_information": [
        {
          "code": "3089700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-AERO          58-79510",
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        {
          "code": "3284351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHARMBER-HEATER MR290",
      "code_information": [
        {
          "code": "3290069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ENDO TUBE ANCHORFAST",
      "code_information": [
        {
          "code": "3290137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-DERMABOND MINI",
      "code_information": [
        {
          "code": "3500037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 180.7325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SPIKE PRIMING   101593",
      "code_information": [
        {
          "code": "3500089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1363.0011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-HYPERINFLATION   1/2 LITER",
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        {
          "code": "3501291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CAPNOLINE 11996-000163",
      "code_information": [
        {
          "code": "3501717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 370.3626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT TALL LF/ALUM 7704",
      "code_information": [
        {
          "code": "3511782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHANNEL ALL JP22xx",
      "code_information": [
        {
          "code": "3512580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 F/PEDS PEDICAP6",
      "code_information": [
        {
          "code": "3512772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL LRG     L-35MM",
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        {
          "code": "3513122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3514273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1634.934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEEDER-SPECIALNEEDS 80ML 6000S",
      "code_information": [
        {
          "code": "3515912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLD MIC 40M SQ40SK",
      "code_information": [
        {
          "code": "3516131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE ALL SZS     N7s",
      "code_information": [
        {
          "code": "3519400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-KNEE 22\\\"   1220917",
      "code_information": [
        {
          "code": "3519967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7089-0844",
      "code_information": [
        {
          "code": "3526221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP839D",
      "code_information": [
        {
          "code": "3526344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP838",
      "code_information": [
        {
          "code": "3526348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 260.8109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTOR-ADULT INTUBATED AIRWAY",
      "code_information": [
        {
          "code": "3526527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GROMMET-BEVELED VENT 70241350",
      "code_information": [
        {
          "code": "3527288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS INF-L",
      "code_information": [
        {
          "code": "3541326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DELIVER MORGAN LENS MT202",
      "code_information": [
        {
          "code": "3541942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 473.7972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD/IV FLUID WARMER L-70",
      "code_information": [
        {
          "code": "3542396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 150.7031,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM PREMIE N4901",
      "code_information": [
        {
          "code": "3549181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 24 JP-2234",
      "code_information": [
        {
          "code": "3549296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3741.9969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOCKS-TISSUE FLT-010",
      "code_information": [
        {
          "code": "3549777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIRROR-INSPECTION DIABETIC 081",
      "code_information": [
        {
          "code": "3550157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 680.1103,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM INFANT N4902",
      "code_information": [
        {
          "code": "3550255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 534.4121,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVES-SKIL-CARE GERI SM 5669",
      "code_information": [
        {
          "code": "3550329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF LG MDS601LD",
      "code_information": [
        {
          "code": "3550554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE,MERSILINE 4-0 S-2 1779G",
      "code_information": [
        {
          "code": "3550847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 438.2068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT ANES 2L 72\\\"",
      "code_information": [
        {
          "code": "3559130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP774D",
      "code_information": [
        {
          "code": "3559182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 31619.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-UNDER NOSE",
      "code_information": [
        {
          "code": "3559270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 417.075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 15 JP-2228",
      "code_information": [
        {
          "code": "3559392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 19 JP-2230",
      "code_information": [
        {
          "code": "3559393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-HUMIDIFER MR290V",
      "code_information": [
        {
          "code": "3559432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 209.6497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET NEO",
      "code_information": [
        {
          "code": "3559609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 657.8663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         C-017-D",
      "code_information": [
        {
          "code": "3560077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4258705",
      "code_information": [
        {
          "code": "3568756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 211.318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-COBAN 2LAYER         2094",
      "code_information": [
        {
          "code": "3575850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 180.7325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND UNIVERSAL RT/LT LG",
      "code_information": [
        {
          "code": "3580012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIV 9006-00",
      "code_information": [
        {
          "code": "3580022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3598026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MAC",
      "code_information": [
        {
          "code": "3598027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LAPAROSCOPIC STR 2190J",
      "code_information": [
        {
          "code": "3598116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-POLY OVAL SOFT WIRE",
      "code_information": [
        {
          "code": "3598262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ARTHROGRAM DYNJ07425",
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        {
          "code": "3598354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAG-DISP SUCT 10’ 30-5201",
      "code_information": [
        {
          "code": "3598648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1 VASC1346",
      "code_information": [
        {
          "code": "3598865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/63-74\\\" 1146PP",
      "code_information": [
        {
          "code": "3598976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-NASAL VIP1137380",
      "code_information": [
        {
          "code": "3599139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 149.5909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-NASAL VIP1137381",
      "code_information": [
        {
          "code": "3599142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 483.807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE RENOVARP GIS-29",
      "code_information": [
        {
          "code": "3599229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 17-22CM",
      "code_information": [
        {
          "code": "3599603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 22-25CM",
      "code_information": [
        {
          "code": "3599604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 25-29CM",
      "code_information": [
        {
          "code": "3599605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 29-36CM",
      "code_information": [
        {
          "code": "3599606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 240014",
      "code_information": [
        {
          "code": "3599773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 836.9305,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SSL",
      "code_information": [
        {
          "code": "3600225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1MSL",
      "code_information": [
        {
          "code": "3600226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1LSL",
      "code_information": [
        {
          "code": "3600227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL WIDE EVO1WSL",
      "code_information": [
        {
          "code": "3600228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 132.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2SSL",
      "code_information": [
        {
          "code": "3600230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2MSL",
      "code_information": [
        {
          "code": "3600231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CN 10MM HEX P45-940-0001",
      "code_information": [
        {
          "code": "3600608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 378.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-JTIP .025X33CM",
      "code_information": [
        {
          "code": "3600780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 542.7536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP726D",
      "code_information": [
        {
          "code": "3601389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 696.7933,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SEDLINE RD",
      "code_information": [
        {
          "code": "3601706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMP SENSING 16FR 119216",
      "code_information": [
        {
          "code": "3601726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PREM CS006",
      "code_information": [
        {
          "code": "3601999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 0 VCPP31D",
      "code_information": [
        {
          "code": "3602463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-INSTRUMENT T50106",
      "code_information": [
        {
          "code": "3603056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 12107.9653,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63447",
      "code_information": [
        {
          "code": "3603065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63446",
      "code_information": [
        {
          "code": "3603066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3603332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 7779.839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-BIOPSY ORT 27550ZAG/10",
      "code_information": [
        {
          "code": "3603541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG GOLD NR30001010",
      "code_information": [
        {
          "code": "3603912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NOMOLINE LH AIRWAY ADAPTER",
      "code_information": [
        {
          "code": "3603959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 662.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED W/ PEEP VALVE",
      "code_information": [
        {
          "code": "3603963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADULT W/ PEEP VAL",
      "code_information": [
        {
          "code": "3603964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION C2202",
      "code_information": [
        {
          "code": "3603996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 6010.3288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP840D",
      "code_information": [
        {
          "code": "3604214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY METER ALL P4PxxULD",
      "code_information": [
        {
          "code": "3084872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 50.049,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8702H",
      "code_information": [
        {
          "code": "3089122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 58.9466,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          JJ31G",
      "code_information": [
        {
          "code": "3089143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C016D",
      "code_information": [
        {
          "code": "3089188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 6-0          1732G",
      "code_information": [
        {
          "code": "3089203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 35.5904,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX41",
      "code_information": [
        {
          "code": "3089216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 60.6149,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J840D",
      "code_information": [
        {
          "code": "3089388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 54.4978,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ9 8.5CM",
      "code_information": [
        {
          "code": "3311077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 47.8246,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PULLEY-OVERDOOR LUM101P",
      "code_information": [
        {
          "code": "3311351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 39.4831,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LTA MADGIC       MAD600",
      "code_information": [
        {
          "code": "3512793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 37.8148,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 J864D",
      "code_information": [
        {
          "code": "3526246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 8X18",
      "code_information": [
        {
          "code": "3526255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 31.1416,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS NEO-L",
      "code_information": [
        {
          "code": "3541327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 30.0294,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH MALE EXTERNAL MECSB01",
      "code_information": [
        {
          "code": "3550510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 33.9221,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 S-14",
      "code_information": [
        {
          "code": "3559177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 37.8148,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2350H",
      "code_information": [
        {
          "code": "3559280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 57.8344,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 1 VCP741D",
      "code_information": [
        {
          "code": "3598416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 45.0441,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NERVE BLOCK 22G HN3S-80",
      "code_information": [
        {
          "code": "3598440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 36.1465,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2LSL",
      "code_information": [
        {
          "code": "3600232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 31.1416,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63445",
      "code_information": [
        {
          "code": "3603067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 55.0539,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE PMITCSG",
      "code_information": [
        {
          "code": "3603191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 41.1514,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER TOP 44X44 ORS-100",
      "code_information": [
        {
          "code": "3011925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 126.7908,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT         PI-104",
      "code_information": [
        {
          "code": "3019880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 55.0539,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 2xFR",
      "code_information": [
        {
          "code": "3058922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 44.488,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 16\\\" 7716-000-10",
      "code_information": [
        {
          "code": "3060133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 56.1661,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNELER 16G     ACC10S",
      "code_information": [
        {
          "code": "3079464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 76.7418,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SEPTAL NEIMAN  14-0441",
      "code_information": [
        {
          "code": "3080203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 67.8442,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMDxx40x",
      "code_information": [
        {
          "code": "3082490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 38.927,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-EYE 10.0          7711G",
      "code_information": [
        {
          "code": "3082557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 35.5904,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXMP1B117",
      "code_information": [
        {
          "code": "3089421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 99.5419,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 3.2MM        702462",
      "code_information": [
        {
          "code": "3091254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 99.5419,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBIGRIP D 1437",
      "code_information": [
        {
          "code": "3503055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH X3-003-000",
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        {
          "code": "3504921",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 93.9809,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 600ML 622278",
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        {
          "code": "3505722",
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      "service_type": "CDM"
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    {
      "description": "CANISTER-VAC FREEDOM 300ML",
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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          ]
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      "service_type": "CDM"
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    {
      "description": "CATH-CRITICORE URINARY  900216",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 94.537,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC ALL SZ",
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        {
          "code": "3510098",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 107.8834,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
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          ]
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      ],
      "service_type": "CDM"
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    {
      "description": "CIRCUIT-OXYLOG 3000 DISPOSABLE",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 80.0784,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COLLECTN BREAST MILK  67's",
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        {
          "code": "3521700",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 40.0392,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
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          ]
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      ],
      "service_type": "CDM"
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    {
      "description": "SENSORMAT-CHAIR-CHEC 65815-030",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 5FR TMI      1154",
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        {
          "code": "3541914",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR A3",
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        {
          "code": "3550415",
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION A495LM",
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        {
          "code": "3559184",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
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              "methodology": "percent of total billed charges",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PROCEDURE PICC W/O PICC",
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        {
          "code": "3570790",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 102.3224,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 18GA    9001C0212",
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        {
          "code": "3590035",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 62.8393,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-POLAR KNEE WRAP-ON",
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        {
          "code": "3598080",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 96.7614,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BONE MARROW 11GX4\\\" BAK451",
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        {
          "code": "3598402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 35.5904,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM BLADED CTB73",
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        {
          "code": "3598438",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 60.6149,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL EVF1XMLSLA",
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        {
          "code": "3600224",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 99.5419,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADS-LACURA VISCO FOOT",
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        {
          "code": "3604310",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 71.1808,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 7FR       06-107F",
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        {
          "code": "1415875",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 MS-DC5020",
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        {
          "code": "3002250",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          MS-DC28",
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        {
          "code": "3002372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DERMATOME 00-8800-000-10",
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        {
          "code": "3002650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-7.3 ARCH AORTIC MT022A",
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        {
          "code": "3004031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHOULDER ALL AR-6500s",
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        {
          "code": "3004216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS HIFLO 24F 69324",
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        {
          "code": "3004482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR        12002",
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        {
          "code": "3004521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 898.1015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-5MM PROT BLUE 5027-1050",
      "code_information": [
        {
          "code": "3004650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 809.6816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-34 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-42 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 17613.3553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-UTERINE MANIPULATOR",
      "code_information": [
        {
          "code": "3019600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MAGNUM BIOPSY    MN18xx",
      "code_information": [
        {
          "code": "3027515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 442.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-PERI-OB DRAPE       2997",
      "code_information": [
        {
          "code": "3034345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-CANNULA XI      470381",
      "code_information": [
        {
          "code": "3039883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 466.0118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-SUTURE ASSISTANT  SW110",
      "code_information": [
        {
          "code": "3039900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 479.3582,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETAINER-VISCERA LARGE HS-3206",
      "code_information": [
        {
          "code": "3040486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 BV-1 BLUE EPH9702H",
      "code_information": [
        {
          "code": "3058802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 44501.9025,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL NEW",
      "code_information": [
        {
          "code": "3059210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN",
      "code_information": [
        {
          "code": "3059265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2961.2325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-VIA-GUARD SMP-2006-001",
      "code_information": [
        {
          "code": "3060015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 519.9535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THREADED 72200425",
      "code_information": [
        {
          "code": "3060484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 741.8374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-ELECTROLUBE         EL101",
      "code_information": [
        {
          "code": "3078867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 697.3494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING           031229-10",
      "code_information": [
        {
          "code": "3079239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-IRRIG SUCT 250070530",
      "code_information": [
        {
          "code": "3083086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 45CM     3909",
      "code_information": [
        {
          "code": "3083636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-ONQ ALL         T1X's",
      "code_information": [
        {
          "code": "3086215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS ADAPTER",
      "code_information": [
        {
          "code": "3087517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 1010030",
      "code_information": [
        {
          "code": "3088591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 300.8501,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 5        RS21",
      "code_information": [
        {
          "code": "3089261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 337.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-BLUE VLOCN0615",
      "code_information": [
        {
          "code": "3089401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             1101",
      "code_information": [
        {
          "code": "3093210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1368.5621,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS 420023",
      "code_information": [
        {
          "code": "3155010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS LONG",
      "code_information": [
        {
          "code": "3155020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION ADJ",
      "code_information": [
        {
          "code": "3311604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD           KVL03",
      "code_information": [
        {
          "code": "3504920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 1L    622283",
      "code_information": [
        {
          "code": "3505720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE A ARTERIAL    400115A",
      "code_information": [
        {
          "code": "3521984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 280.8305,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-KIWI OMNI SYSTEM",
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        {
          "code": "3522453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 650.0809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22G X 20CM",
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        {
          "code": "3526117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PULSAVAC IRRIGATION",
      "code_information": [
        {
          "code": "3526128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 44501.9025,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CYSTO           DYNJ49183",
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        {
          "code": "3526166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-KENNEDY SINUS      400426",
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        {
          "code": "3526168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 9787.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 30 SXPP1B410",
      "code_information": [
        {
          "code": "3526382",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 34 DPSB 60707010600",
      "code_information": [
        {
          "code": "3526496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1082.7267,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMD2B401",
      "code_information": [
        {
          "code": "3526937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-HEEL SUSPENSION   M60-300",
      "code_information": [
        {
          "code": "3528097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 528.295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 42 DPSB 60707010700",
      "code_information": [
        {
          "code": "3529497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ZONE NAVIGATOR AR790x",
      "code_information": [
        {
          "code": "3547988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K OLIVE 2MM 703818",
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        {
          "code": "3549171",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAGITTAL 40X14X0.6",
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        {
          "code": "3549447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 5MM 0227-010-250",
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        {
          "code": "3549930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-INTRACK ULTRA 66MM",
      "code_information": [
        {
          "code": "3550346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-C1/T1/MR1 EXPIRATORY 161",
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        {
          "code": "3550566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-COAXIAL BREATHING DISP",
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        {
          "code": "3550567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 774.0912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-WHEELCHAIR MEDIUM 565613",
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        {
          "code": "3550733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE",
      "code_information": [
        {
          "code": "3550798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 959.8286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.25X200MM A-5040.30/1",
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        {
          "code": "3550826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DELUXE KNEE/HIP 081603273",
      "code_information": [
        {
          "code": "3550839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4881.4458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTERPULSE HANDLE W TIP",
      "code_information": [
        {
          "code": "3550870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 12MM ONB12STF",
      "code_information": [
        {
          "code": "3559126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AF541",
      "code_information": [
        {
          "code": "3559226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 6901.201,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ4",
      "code_information": [
        {
          "code": "3559252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URI-CATH 3.5FR&5.0FR",
      "code_information": [
        {
          "code": "3566802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
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        {
          "code": "3573907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF 7.0MM",
      "code_information": [
        {
          "code": "3573939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 625.6125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 8.0MM",
      "code_information": [
        {
          "code": "3590138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 15' 251015J",
      "code_information": [
        {
          "code": "3598139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4336.4678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMP2B401",
      "code_information": [
        {
          "code": "3598157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 6183.2759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER PAD F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 539.9731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH 5FR TMI1185",
      "code_information": [
        {
          "code": "3598221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 21028.3654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSPAC TRIFURCATED 42800",
      "code_information": [
        {
          "code": "3598244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 331.9917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4X70/16MM 607470",
      "code_information": [
        {
          "code": "3598460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 314.7526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 GORE-TEX 4N10B",
      "code_information": [
        {
          "code": "3598958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1007.6532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 18 FR",
      "code_information": [
        {
          "code": "3599116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 16 FR",
      "code_information": [
        {
          "code": "3599117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-NITINOL PILOT 5901-6072",
      "code_information": [
        {
          "code": "3599187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/25CM MN1825",
      "code_information": [
        {
          "code": "3599317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4392.0778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSIONS-CABLE DISP 4051L",
      "code_information": [
        {
          "code": "3599647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4002.8078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.1CM",
      "code_information": [
        {
          "code": "3600164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 336.4405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.6X150MM P99-292-1615",
      "code_information": [
        {
          "code": "3600326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 900.3259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-CAPTURA DISP G53006",
      "code_information": [
        {
          "code": "3600504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 989.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-192-2330",
      "code_information": [
        {
          "code": "3600521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TENNIS RACQUET 5FR/90CM",
      "code_information": [
        {
          "code": "3600554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 989.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ 3",
      "code_information": [
        {
          "code": "3600778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 28621.9109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-2.0X200MM P99-192-2020",
      "code_information": [
        {
          "code": "3601106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1091.6243,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,GASTRO MIC",
      "code_information": [
        {
          "code": "3601451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 876.9697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MIAR 14G 7FR 11014L",
      "code_information": [
        {
          "code": "3601478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 283.611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-OSIA OSI200 P1291019",
      "code_information": [
        {
          "code": "3601610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300 NTHRD 702463",
      "code_information": [
        {
          "code": "3601870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-193-2323",
      "code_information": [
        {
          "code": "3602140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.1MM AR-8655K-11",
      "code_information": [
        {
          "code": "3602154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SHEATH W/CATH SA-09847",
      "code_information": [
        {
          "code": "3602436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PT PUMP 8\\\"\\\" AR-6421",
      "code_information": [
        {
          "code": "3602461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2892.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-RING 16\\\" DUR8016W",
      "code_information": [
        {
          "code": "3602526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.2X150 TH P99-193-1215",
      "code_information": [
        {
          "code": "3602570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP TRB29-LRG",
      "code_information": [
        {
          "code": "3602758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.0X200MM P99-193-2020",
      "code_information": [
        {
          "code": "3602993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 877.5258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X100MM P99-192-1410",
      "code_information": [
        {
          "code": "3603370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-BIVENTRICULAR BS-101-97",
      "code_information": [
        {
          "code": "3603546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 3-0 PS-2",
      "code_information": [
        {
          "code": "3603921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.4X15 MSG14150",
      "code_information": [
        {
          "code": "3604046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.6X15 MSG16150",
      "code_information": [
        {
          "code": "3604056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 7516.2476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X150MM P99-292-0915",
      "code_information": [
        {
          "code": "3604177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X150 SM P99-192-2315",
      "code_information": [
        {
          "code": "3604181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-292-1115",
      "code_information": [
        {
          "code": "3604182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1615",
      "code_information": [
        {
          "code": "3604183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1415",
      "code_information": [
        {
          "code": "3604184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-U-FRAME STRD MT-APU-2.4",
      "code_information": [
        {
          "code": "3604229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 868.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-HEX 10MM 76-10185",
      "code_information": [
        {
          "code": "3604312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-GUARDIAN HEMOSTAT 8215",
      "code_information": [
        {
          "code": "3604336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 519.3974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-WASTE 04369",
      "code_information": [
        {
          "code": "3604367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 7227.6317,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K .9X150MM P99-192-0915",
      "code_information": [
        {
          "code": "3604377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG 900-152",
      "code_information": [
        {
          "code": "3604585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD-EX 900-154",
      "code_information": [
        {
          "code": "3604586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD 900-151",
      "code_information": [
        {
          "code": "3604587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG-SHL 900-155",
      "code_information": [
        {
          "code": "3604588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FINGER SMALL 9906",
      "code_information": [
        {
          "code": "3604630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "1100160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYN            ALLSZs",
      "code_information": [
        {
          "code": "1100275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.8871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC PED 10FR    8010",
      "code_information": [
        {
          "code": "1102034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 12FR PEDS   8012",
      "code_information": [
        {
          "code": "1102046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.9081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK BABY",
      "code_information": [
        {
          "code": "1102135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.6357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC 3-LUMEN PWR INJ SAFET",
      "code_information": [
        {
          "code": "1110365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 477.3578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH LUMEN 4FR    AK-14402",
      "code_information": [
        {
          "code": "1110376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "1113245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS          G04153",
      "code_information": [
        {
          "code": "1113258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.8638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-FOREIGN BODY   FB-5000",
      "code_information": [
        {
          "code": "1115735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 837,
          "minimum": 175.77,
          "maximum": 612.8514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.9237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEONATE TUBE RESV",
      "code_information": [
        {
          "code": "1115845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATHETER CRICOTHYROTOMY",
      "code_information": [
        {
          "code": "1118135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1639,
          "minimum": 344.19,
          "maximum": 1200.0758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1020.0644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-HANGING CAST LG 1180LPP",
      "code_information": [
        {
          "code": "1118520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "1118720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "1118735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.6977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "#1855G 5-0 ETHILON PC-1",
      "code_information": [
        {
          "code": "1118792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 49,
          "minimum": 10.29,
          "maximum": 35.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 30.4961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EVAC/DRAIN 1-BTL  62287",
      "code_information": [
        {
          "code": "1118801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED       8CFN",
      "code_information": [
        {
          "code": "1118955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 339,
          "minimum": 71.19,
          "maximum": 248.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 210.9834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "1119001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 41,
          "minimum": 8.61,
          "maximum": 30.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 25.5172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "1119800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 48,
          "minimum": 10.08,
          "maximum": 35.1456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 29.8738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-15      G00012",
      "code_information": [
        {
          "code": "1410067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINL 22X20     G03542",
      "code_information": [
        {
          "code": "1410472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 256,
          "minimum": 53.76,
          "maximum": 187.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.3267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CUSTOM WASTE BAG",
      "code_information": [
        {
          "code": "1410792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 116.3832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-INDIGO W/TUBING IAPS2",
      "code_information": [
        {
          "code": "1410803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1503.6459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INFUSION MRI          1056",
      "code_information": [
        {
          "code": "1410839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE ADAPTER MRI   1057",
      "code_information": [
        {
          "code": "1410840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 131.9424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18G 20CM   G01047",
      "code_information": [
        {
          "code": "1410918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.3345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1411090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18-15      G03954",
      "code_information": [
        {
          "code": "1411193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.0543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MONOPTY 18X10    121810",
      "code_information": [
        {
          "code": "1411612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.9557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JAR-COPLIN PP STAIN     S90130",
      "code_information": [
        {
          "code": "1411903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.5725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION     CID-20-30",
      "code_information": [
        {
          "code": "1412310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 734,
          "minimum": 154.14,
          "maximum": 537.4348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 456.8196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE .010-.038   TD01",
      "code_information": [
        {
          "code": "1412325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-STAYFIX SMALL    680-ME",
      "code_information": [
        {
          "code": "1412330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.7121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL IV 6FR   48-152",
      "code_information": [
        {
          "code": "1412380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL ALL 48-100's",
      "code_information": [
        {
          "code": "1412394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX ALL SZ",
      "code_information": [
        {
          "code": "1413165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 367.8207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX ALL SZ",
      "code_information": [
        {
          "code": "1413170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 523,
          "minimum": 109.83,
          "maximum": 382.9406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 325.4995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-20      G00810",
      "code_information": [
        {
          "code": "1414825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN ALL SZS G01xxx",
      "code_information": [
        {
          "code": "1414845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY ALL SZS",
      "code_information": [
        {
          "code": "1414866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.1296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-10      G01112",
      "code_information": [
        {
          "code": "1414935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "1414990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.9004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X     C20xxA",
      "code_information": [
        {
          "code": "1414995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.5858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-IV SILVERSITE 1X7MM",
      "code_information": [
        {
          "code": "1415449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT GASTRO INITIAL SM",
      "code_information": [
        {
          "code": "1415943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 987,
          "minimum": 207.27,
          "maximum": 722.6814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 614.2792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-150 ML ILLUMENA 900103",
      "code_information": [
        {
          "code": "1416100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGIOGRAPHY    MCBK001-07",
      "code_information": [
        {
          "code": "1416236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 783,
          "minimum": 164.43,
          "maximum": 573.3126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 487.3157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22FR   0250-22",
      "code_information": [
        {
          "code": "1416370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENTUIT THRIVE 14F",
      "code_information": [
        {
          "code": "1416371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 713,
          "minimum": 149.73,
          "maximum": 522.0586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 443.7498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-INDIGO             IST3",
      "code_information": [
        {
          "code": "1416377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2920,
          "minimum": 613.2,
          "maximum": 2138.024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1817.3204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1419101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX11C",
      "code_information": [
        {
          "code": "1419112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX15C",
      "code_information": [
        {
          "code": "1419113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 20GX15C",
      "code_information": [
        {
          "code": "1419114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX11C",
      "code_information": [
        {
          "code": "1419116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX15C",
      "code_information": [
        {
          "code": "1419118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 601,
          "minimum": 126.21,
          "maximum": 440.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 374.0444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX20C",
      "code_information": [
        {
          "code": "1419119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 601,
          "minimum": 126.21,
          "maximum": 440.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 374.0444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY  20GX11C",
      "code_information": [
        {
          "code": "1419293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 451,
          "minimum": 94.71,
          "maximum": 330.2222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.6889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-BIOPSY EVIVA 9G",
      "code_information": [
        {
          "code": "1495152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-TISSUE ATEC        TF-1",
      "code_information": [
        {
          "code": "1495228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-EVIVA STX   0913-12T",
      "code_information": [
        {
          "code": "1495304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE MULTICARE  MME-00347",
      "code_information": [
        {
          "code": "1495418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.5571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC",
      "code_information": [
        {
          "code": "2395902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC 50MM",
      "code_information": [
        {
          "code": "2395904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAT-SURGISAFE ABSORBANT FLOOR",
      "code_information": [
        {
          "code": "3000001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 323,
          "minimum": 67.83,
          "maximum": 236.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.0255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-FULL RADIUS 5.5MM",
      "code_information": [
        {
          "code": "3000006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO               2C4040",
      "code_information": [
        {
          "code": "3000090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CONFIDENCE 2839-99-002",
      "code_information": [
        {
          "code": "3000520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-HEMOSTASES  HC0001",
      "code_information": [
        {
          "code": "3000742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1597,
          "minimum": 335.37,
          "maximum": 1169.3234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 993.9249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-CLIP MED/LG 20 SMC",
      "code_information": [
        {
          "code": "3000753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 626.7266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP PK AM0004",
      "code_information": [
        {
          "code": "3000760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.7044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP    AM0005",
      "code_information": [
        {
          "code": "3000762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP  DISP   MCM20",
      "code_information": [
        {
          "code": "3000765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 518,
          "minimum": 108.78,
          "maximum": 379.2796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 322.3877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP LARGE MCL20",
      "code_information": [
        {
          "code": "3000766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 553,
          "minimum": 116.13,
          "maximum": 404.9066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.1706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP SM MCS20",
      "code_information": [
        {
          "code": "3000767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 569,
          "minimum": 119.49,
          "maximum": 416.6218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 354.1285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-AUTOMATIC 5MM AE05ML",
      "code_information": [
        {
          "code": "3000770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGAMAX 5MM CLIP EL5ML",
      "code_information": [
        {
          "code": "3000771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1389,
          "minimum": 291.69,
          "maximum": 1017.0258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 864.4719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSISTANT-SUTURE 5MM     SW100",
      "code_information": [
        {
          "code": "3000865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1311,
          "minimum": 275.31,
          "maximum": 959.9142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 815.9271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-UROLOGIC DRAIN     9501000",
      "code_information": [
        {
          "code": "3001113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 122.6069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-ANCHOR TISSUE ROBOTIC",
      "code_information": [
        {
          "code": "3001135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 403.9181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-ENDOPOUCH 10MM POUCH",
      "code_information": [
        {
          "code": "3001190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-DISPOSA 3MM       DBL-311",
      "code_information": [
        {
          "code": "3001371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IPRISM IPC05",
      "code_information": [
        {
          "code": "3001669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAR-TIBIAL LOCKING      141205",
      "code_information": [
        {
          "code": "3002092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1493,
          "minimum": 313.53,
          "maximum": 1093.1746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 929.1984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 1.9X120 390-201",
      "code_information": [
        {
          "code": "3002152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1576,
          "minimum": 330.96,
          "maximum": 1153.9472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 980.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOFILTER-ASP FLTR",
      "code_information": [
        {
          "code": "3002210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 508,
          "minimum": 106.68,
          "maximum": 371.9576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CEMENT-COMPACT VACUUM",
      "code_information": [
        {
          "code": "3002214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.8152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           315.48",
      "code_information": [
        {
          "code": "3002244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.2      310.65",
      "code_information": [
        {
          "code": "3002246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MINI DRILL AT2M-1813",
      "code_information": [
        {
          "code": "3002257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1353.6547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145   03.010.104",
      "code_information": [
        {
          "code": "3002260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1668,
          "minimum": 350.28,
          "maximum": 1221.3096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1038.1132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    351.27",
      "code_information": [
        {
          "code": "3002270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3542,
          "minimum": 743.82,
          "maximum": 2593.4524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2204.4345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM      03.010.036",
      "code_information": [
        {
          "code": "3002274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3373,
          "minimum": 708.33,
          "maximum": 2469.7106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2099.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.060",
      "code_information": [
        {
          "code": "3002289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2190,
          "minimum": 459.9,
          "maximum": 1603.518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1362.9903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5           310.23",
      "code_information": [
        {
          "code": "3002291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 937,
          "minimum": 196.77,
          "maximum": 686.0714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 583.1607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM         310.19",
      "code_information": [
        {
          "code": "3002294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 949,
          "minimum": 199.29,
          "maximum": 694.8578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 590.6291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MMX150MM  511.417",
      "code_information": [
        {
          "code": "3002302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1642,
          "minimum": 344.82,
          "maximum": 1202.2724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1021.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2 ALL 1806-4200s",
      "code_information": [
        {
          "code": "3002305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1134,
          "minimum": 238.14,
          "maximum": 830.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 705.7676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X180MM 1806-4270S",
      "code_information": [
        {
          "code": "3002306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 756.8019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR        5091-206",
      "code_information": [
        {
          "code": "3002318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR",
      "code_information": [
        {
          "code": "3002324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-STEP DRILL         357.403",
      "code_information": [
        {
          "code": "3002361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3578,
          "minimum": 751.38,
          "maximum": 2619.8116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2226.8399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.4     310.530",
      "code_information": [
        {
          "code": "3002365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1282,
          "minimum": 269.22,
          "maximum": 938.6804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 797.8783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           1806-5020S",
      "code_information": [
        {
          "code": "3002379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1219,
          "minimum": 255.99,
          "maximum": 892.5518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 758.669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM        388.394",
      "code_information": [
        {
          "code": "3002383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         60-20385",
      "code_information": [
        {
          "code": "3002391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 685.8517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 03.113.024",
      "code_information": [
        {
          "code": "3002394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1440,
          "minimum": 302.4,
          "maximum": 1054.368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 896.2128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 03.113.023",
      "code_information": [
        {
          "code": "3002399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1440,
          "minimum": 302.4,
          "maximum": 1054.368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 896.2128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM 703542",
      "code_information": [
        {
          "code": "3002400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 799.1231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3MM 703541",
      "code_information": [
        {
          "code": "3002402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1335,
          "minimum": 280.35,
          "maximum": 977.487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 830.8639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5085-2-032",
      "code_information": [
        {
          "code": "3002403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM 5085-2-040",
      "code_information": [
        {
          "code": "3002410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 1.7MM",
      "code_information": [
        {
          "code": "3002760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1755,
          "minimum": 368.55,
          "maximum": 1285.011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1092.2594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO        1806-5000S",
      "code_information": [
        {
          "code": "3002772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1103,
          "minimum": 231.63,
          "maximum": 807.6166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 686.4741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM     03.010.061",
      "code_information": [
        {
          "code": "3002776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2190,
          "minimum": 459.9,
          "maximum": 1603.518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1362.9903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM    03.010.101S",
      "code_information": [
        {
          "code": "3002777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1353.6547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.6x",
      "code_information": [
        {
          "code": "3002779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2769,
          "minimum": 581.49,
          "maximum": 2027.4618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1723.3425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL W/STOP ALL   324.15x",
      "code_information": [
        {
          "code": "3002780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2797,
          "minimum": 587.37,
          "maximum": 2047.9634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1740.7689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.68",
      "code_information": [
        {
          "code": "3002782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2977,
          "minimum": 625.17,
          "maximum": 2179.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1852.7955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 17MM    357.394",
      "code_information": [
        {
          "code": "3002785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4976,
          "minimum": 1044.96,
          "maximum": 3643.4272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3096.9131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM         700347",
      "code_information": [
        {
          "code": "3002791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1337,
          "minimum": 280.77,
          "maximum": 978.9514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 832.1087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1MM         702742",
      "code_information": [
        {
          "code": "3002793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1019,
          "minimum": 213.99,
          "maximum": 746.1118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 634.195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X110MM     310.35",
      "code_information": [
        {
          "code": "3002794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 921,
          "minimum": 193.41,
          "maximum": 674.3562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 573.2028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER MINI       376900",
      "code_information": [
        {
          "code": "3002835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 9-9.5MM 5400-031-xxx",
      "code_information": [
        {
          "code": "3002951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1113,
          "minimum": 233.73,
          "maximum": 814.9386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.6978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EXT ELECTRODE    E1551-6",
      "code_information": [
        {
          "code": "3002959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-TURBINATE INF SB2000SA",
      "code_information": [
        {
          "code": "3002962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1139,
          "minimum": 239.19,
          "maximum": 833.9758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.8794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SERRATED STND SB4000SS",
      "code_information": [
        {
          "code": "3002963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 809.081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MYRINGOTOMY SPEAR TIP",
      "code_information": [
        {
          "code": "3003112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RAD 40 DEGREE 18-84006HR",
      "code_information": [
        {
          "code": "3003122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1727,
          "minimum": 362.67,
          "maximum": 1264.5094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1074.833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RADNOID 18-84008",
      "code_information": [
        {
          "code": "3003123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1721,
          "minimum": 361.41,
          "maximum": 1260.1162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1071.0988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RASP SAW       510037113",
      "code_information": [
        {
          "code": "3003127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 689.586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW MICR 9MM 2296-3-100s",
      "code_information": [
        {
          "code": "3003143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 324.2548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG SAW 9X25 ALL 2296s",
      "code_information": [
        {
          "code": "3003147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 324.2548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 5.5MMX18MM  KM 3-412",
      "code_information": [
        {
          "code": "3003150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW GIGLI ROUND  2808-01",
      "code_information": [
        {
          "code": "3003172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HEX COATED 2.75   E1450X",
      "code_information": [
        {
          "code": "3003200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-INF TURB 2.0  18-82040HR",
      "code_information": [
        {
          "code": "3003227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2469,
          "minimum": 518.49,
          "maximum": 1807.8018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1536.6315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD DISP   8000-140",
      "code_information": [
        {
          "code": "3003251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 142.5227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90Xxx    05.003.1xxS",
      "code_information": [
        {
          "code": "3003256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 388.3589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380HR",
      "code_information": [
        {
          "code": "3003258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1739,
          "minimum": 365.19,
          "maximum": 1273.2958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1082.3014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380EM",
      "code_information": [
        {
          "code": "3003259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1984.1156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS     519.xxxS",
      "code_information": [
        {
          "code": "3003292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 482.9591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CELL SAVER HI SP   CSP26x",
      "code_information": [
        {
          "code": "3003419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 777,
          "minimum": 163.17,
          "maximum": 568.9194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 483.5815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-SMARTMIX CTS    540176501",
      "code_information": [
        {
          "code": "3003433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-INTERNAL AR-1678-CP",
      "code_information": [
        {
          "code": "3003471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5500,
          "minimum": 1155,
          "maximum": 4027.1,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3423.035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-UNIV X-ACT 11-2151-9",
      "code_information": [
        {
          "code": "3003472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 998,
          "minimum": 209.58,
          "maximum": 730.7356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 621.1253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-COLON CYTO        000110",
      "code_information": [
        {
          "code": "3003503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.2016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-WHISTLE CLEANING  000101",
      "code_information": [
        {
          "code": "3003605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.9081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT RND 2296-100-421",
      "code_information": [
        {
          "code": "3003756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL CUTTING 5300-010-901",
      "code_information": [
        {
          "code": "3003762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.0189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND          277-10-423",
      "code_information": [
        {
          "code": "3003782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND CUT 2.4MM  5091-225",
      "code_information": [
        {
          "code": "3003786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 150.6135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT 1.6   277-10-xxx",
      "code_information": [
        {
          "code": "3003792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-WATERMELON      1607-2-35",
      "code_information": [
        {
          "code": "3003805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 388.3589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL   SP-7810",
      "code_information": [
        {
          "code": "3003812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 792.8994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 2MM 5820-013-0xx",
      "code_information": [
        {
          "code": "3003829",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 794.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND S03.000.009S",
      "code_information": [
        {
          "code": "3003841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.0798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND 4.0MM    277-10-240",
      "code_information": [
        {
          "code": "3003855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.0465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 5MM     5820-013-050",
      "code_information": [
        {
          "code": "3003856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING BLUE   FL-601-97B",
      "code_information": [
        {
          "code": "3003905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT STERILE MAS PLIF",
      "code_information": [
        {
          "code": "3003914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1775.6216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ARCH 6.5  80320",
      "code_information": [
        {
          "code": "3004042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.6756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO DBL 5MM PAL-505LL",
      "code_information": [
        {
          "code": "3004047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY PREMATURE",
      "code_information": [
        {
          "code": "3004048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.4673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY NEONATAL",
      "code_information": [
        {
          "code": "3004049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.4673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERPAY INFANT",
      "code_information": [
        {
          "code": "3004051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.4673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-308LS",
      "code_information": [
        {
          "code": "3004052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 460.5538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CURVED 100MM 20G 10.0M",
      "code_information": [
        {
          "code": "3004190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX FEM TFA-022-25",
      "code_information": [
        {
          "code": "3004225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.0233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX       TFA02025",
      "code_information": [
        {
          "code": "3004226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.0233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 27FR 96370-027",
      "code_information": [
        {
          "code": "3004235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1777,
          "minimum": 373.17,
          "maximum": 1301.1194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1105.9515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-I-STAT CREATININE",
      "code_information": [
        {
          "code": "3004750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 22FR 30CC      266722",
      "code_information": [
        {
          "code": "3004837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.0764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-5FR RAD PIGTAIL 5RPS110-N",
      "code_information": [
        {
          "code": "3004842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 364,
          "minimum": 76.44,
          "maximum": 266.5208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 226.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TACKER DELIVERY OMS-TTS",
      "code_information": [
        {
          "code": "3005077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3218,
          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2002.7867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHLOANGIOGRAM   20018-010",
      "code_information": [
        {
          "code": "3005234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 613,
          "minimum": 128.73,
          "maximum": 448.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 381.5128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 24Fr 5CC 265724",
      "code_information": [
        {
          "code": "3005414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3WAY         73022L",
      "code_information": [
        {
          "code": "3005435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.2924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 34FR-46FR ALL",
      "code_information": [
        {
          "code": "3007230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.6457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 36FR-46FR  TF36460",
      "code_information": [
        {
          "code": "3007235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.6457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP         AA01",
      "code_information": [
        {
          "code": "3007600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-ACU-DISPO      DCFT2",
      "code_information": [
        {
          "code": "3007601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP,MULTI-PIN LG 390.004",
      "code_information": [
        {
          "code": "3008494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4727,
          "minimum": 992.67,
          "maximum": 3461.1094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2941.943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-NV DSC & IN-LINE ACTIVATO",
      "code_information": [
        {
          "code": "3008690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LAPRA-TY ABS SUTURE XC200",
      "code_information": [
        {
          "code": "3008699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 777,
          "minimum": 163.17,
          "maximum": 568.9194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 483.5815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIPS-HEM-O-LOC         544230",
      "code_information": [
        {
          "code": "3008728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK LG       544240",
      "code_information": [
        {
          "code": "3008730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK XL       544250",
      "code_information": [
        {
          "code": "3008731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X3/8 XA6062",
      "code_information": [
        {
          "code": "3009659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 871,
          "minimum": 182.91,
          "maximum": 637.7462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 542.0843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR ACCU-FLO 82-1504",
      "code_information": [
        {
          "code": "3009774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 705.1452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONSTAVAC-CBC II    225-28-614",
      "code_information": [
        {
          "code": "3009792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1463,
          "minimum": 307.23,
          "maximum": 1071.2086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 910.5273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR BOVIE DISP 301538",
      "code_information": [
        {
          "code": "3009842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR HIGH   26176LD/10",
      "code_information": [
        {
          "code": "3009843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.2636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNULATED",
      "code_information": [
        {
          "code": "3009845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1933,
          "minimum": 405.93,
          "maximum": 1415.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1203.0412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNUL 3.8MM",
      "code_information": [
        {
          "code": "3009850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1119.6436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-SILICONE RETRACTOR",
      "code_information": [
        {
          "code": "3009851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.0133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-DISPOSABLE ACTIVE DAC",
      "code_information": [
        {
          "code": "3009853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 177.3755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-8 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.5715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 177.3755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 216.5848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-30 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 428,
          "minimum": 89.88,
          "maximum": 313.3816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 266.3744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 291.8915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CORONARY PERF    30055",
      "code_information": [
        {
          "code": "3010039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MERCEDES     PAL-506LL",
      "code_information": [
        {
          "code": "3010053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS ALL SZS   681xx",
      "code_information": [
        {
          "code": "3010076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 551,
          "minimum": 115.71,
          "maximum": 403.4422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 342.9259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT ALL SZ",
      "code_information": [
        {
          "code": "3010079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL 1X4  2111-04-077",
      "code_information": [
        {
          "code": "3010088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2712,
          "minimum": 569.52,
          "maximum": 1985.7264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1687.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL ALL  2111-08-07x",
      "code_information": [
        {
          "code": "3010090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5695,
          "minimum": 1195.95,
          "maximum": 4169.879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3544.3971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X20 657320",
      "code_information": [
        {
          "code": "3010104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X40 657340",
      "code_information": [
        {
          "code": "3010107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DUBIN              8390",
      "code_information": [
        {
          "code": "3010215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION         BID30",
      "code_information": [
        {
          "code": "3010259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 890,
          "minimum": 186.9,
          "maximum": 651.658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 553.9093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE LITE 30-403LITE",
      "code_information": [
        {
          "code": "3010311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3419,
          "minimum": 717.99,
          "maximum": 2503.3918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2127.883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LAPARSCOP PLUME FILTER",
      "code_information": [
        {
          "code": "3010330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.2293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VAGINAL POSITIONING",
      "code_information": [
        {
          "code": "3010598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2367,
          "minimum": 497.07,
          "maximum": 1733.1174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1473.1498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-BLUNT TIP 5 PK BTD05",
      "code_information": [
        {
          "code": "3010867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1 5901-1126",
      "code_information": [
        {
          "code": "3011002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHAN W/TROCAR ALL SIZES",
      "code_information": [
        {
          "code": "3011730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 199,
          "minimum": 41.79,
          "maximum": 145.7078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.8516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT HUBLESS ALL SZS",
      "code_information": [
        {
          "code": "3011780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-MINI CHEST 500     16400",
      "code_information": [
        {
          "code": "3011787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1139,
          "minimum": 239.19,
          "maximum": 833.9758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 708.8794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FECAL MANAGEMENT 418000",
      "code_information": [
        {
          "code": "3011910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1469,
          "minimum": 308.49,
          "maximum": 1075.6018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 914.2615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FECAL MANAGEMENT 411108",
      "code_information": [
        {
          "code": "3011911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-HIP W/POUCHES DYNJP8201",
      "code_information": [
        {
          "code": "3011920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.0543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BEACH CHAIR SHOULDER",
      "code_information": [
        {
          "code": "3011922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 257,
          "minimum": 53.97,
          "maximum": 188.1754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.9491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BARIATRIC      DYNJP3105",
      "code_information": [
        {
          "code": "3011926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.9004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-DOUBLE 44X66     ORS 320",
      "code_information": [
        {
          "code": "3011927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 303.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 12MM CD004",
      "code_information": [
        {
          "code": "3011949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE 3M SHORT   6661EZ",
      "code_information": [
        {
          "code": "3011953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-ISO IOBAN HIP       6617",
      "code_information": [
        {
          "code": "3011959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.1728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INTESTINAL 18X18.5 ISO1003",
      "code_information": [
        {
          "code": "3011960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 360,
          "minimum": 75.6,
          "maximum": 263.592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.0532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 10MM CD001",
      "code_information": [
        {
          "code": "3011961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI     326088-0000-000",
      "code_information": [
        {
          "code": "3011985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI FULL         306070",
      "code_information": [
        {
          "code": "3011987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 279,
          "minimum": 58.59,
          "maximum": 204.2838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER           ORS-400",
      "code_information": [
        {
          "code": "3011995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 367.8207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERI IRRIGATION    1016",
      "code_information": [
        {
          "code": "3012018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE HAND   DYNJP8005",
      "code_information": [
        {
          "code": "3012025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR GLASSCOCK  S-1000",
      "code_information": [
        {
          "code": "3012051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.5571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GENTLE CARE SURG 12-1",
      "code_information": [
        {
          "code": "3012060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 480,
          "minimum": 100.8,
          "maximum": 351.456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 298.7376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-TOPIFOAM      5710-30",
      "code_information": [
        {
          "code": "3012080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN TWIST 2.7MM W/AO F",
      "code_information": [
        {
          "code": "3012109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2077,
          "minimum": 436.17,
          "maximum": 1520.7794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1292.6625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.0MM ASNIS",
      "code_information": [
        {
          "code": "3012113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1913,
          "minimum": 401.73,
          "maximum": 1400.6986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1190.5938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-HEX 1.1X67       15-1723",
      "code_information": [
        {
          "code": "3012115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1211,
          "minimum": 254.31,
          "maximum": 886.6942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 753.6901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3012118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN 4.0MM W/AO",
      "code_information": [
        {
          "code": "3012152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5392,
          "minimum": 1132.32,
          "maximum": 3948.0224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3355.819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SHAFT-AO 2.6MMX122MM",
      "code_information": [
        {
          "code": "3012186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 909.9049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           310.48",
      "code_information": [
        {
          "code": "3012201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1176,
          "minimum": 246.96,
          "maximum": 861.0672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 731.9071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO SMALL  1320-3042S",
      "code_information": [
        {
          "code": "3012204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1181,
          "minimum": 248.01,
          "maximum": 864.7282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 735.019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1806-5010S",
      "code_information": [
        {
          "code": "3012206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1103,
          "minimum": 231.63,
          "maximum": 807.6166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 686.4741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 03.6MMX122MM",
      "code_information": [
        {
          "code": "3012207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1378,
          "minimum": 289.38,
          "maximum": 1008.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 857.6259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM       60-19326",
      "code_information": [
        {
          "code": "3012208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.0754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 13.0MM CANNULATED",
      "code_information": [
        {
          "code": "3012314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4464,
          "minimum": 937.44,
          "maximum": 3268.5408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2778.2597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0           310.21",
      "code_information": [
        {
          "code": "3012318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.9436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         MS-DCR20",
      "code_information": [
        {
          "code": "3012321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.7399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 LG 120MM",
      "code_information": [
        {
          "code": "3012325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1725,
          "minimum": 362.25,
          "maximum": 1263.045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1073.5883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 315.28",
      "code_information": [
        {
          "code": "3012330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1374,
          "minimum": 288.54,
          "maximum": 1006.0428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 855.1364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          310.288",
      "code_information": [
        {
          "code": "3012331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2           405883",
      "code_information": [
        {
          "code": "3012341",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1098,
          "minimum": 230.58,
          "maximum": 803.9556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 683.3623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X40   2274-12-000",
      "code_information": [
        {
          "code": "3012344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1940,
          "minimum": 407.4,
          "maximum": 1420.468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1207.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5          MS-DC35",
      "code_information": [
        {
          "code": "3012346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1055,
          "minimum": 221.55,
          "maximum": 772.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 656.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.201",
      "code_information": [
        {
          "code": "3012355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 912,
          "minimum": 191.52,
          "maximum": 667.7664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 567.6014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL               310.28",
      "code_information": [
        {
          "code": "3012356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.9436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.431",
      "code_information": [
        {
          "code": "3012357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1411,
          "minimum": 296.31,
          "maximum": 1033.1342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 878.1641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL            32-486265",
      "code_information": [
        {
          "code": "3012365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 769,
          "minimum": 161.49,
          "maximum": 563.0618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 478.6025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL         5820-107-530",
      "code_information": [
        {
          "code": "3012374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           AT2M-L1813",
      "code_information": [
        {
          "code": "3012378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2410,
          "minimum": 506.1,
          "maximum": 1764.602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1499.9117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED   310.634",
      "code_information": [
        {
          "code": "3012380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1663.595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 5.0MM",
      "code_information": [
        {
          "code": "3012381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1663.595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM 60-19340",
      "code_information": [
        {
          "code": "3012401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 685.8517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHRT 3.2 03.010.103S",
      "code_information": [
        {
          "code": "3012406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1666,
          "minimum": 349.86,
          "maximum": 1219.8452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1036.8684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL 5MM     DBL-511",
      "code_information": [
        {
          "code": "3012461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL LOOP      B0512",
      "code_information": [
        {
          "code": "3012465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X2.75 E1455",
      "code_information": [
        {
          "code": "3012472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X4  E1455-4",
      "code_information": [
        {
          "code": "3012473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-208",
      "code_information": [
        {
          "code": "3012474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1372,
          "minimum": 288.12,
          "maximum": 1004.5784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.8916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EZ CLEAN CAUTERY TIP",
      "code_information": [
        {
          "code": "3012505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE MOD     0014AM",
      "code_information": [
        {
          "code": "3012507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BOVIE RED      E7507",
      "code_information": [
        {
          "code": "3012513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK  E2773-45",
      "code_information": [
        {
          "code": "3012520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 259.5283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MRI CONDITIONAL DISP",
      "code_information": [
        {
          "code": "3012521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LIGASURE      LS1037",
      "code_information": [
        {
          "code": "3012535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2512,
          "minimum": 527.52,
          "maximum": 1839.2864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1563.3934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 2CHAN 8227410",
      "code_information": [
        {
          "code": "3012585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1545,
          "minimum": 324.45,
          "maximum": 1131.249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 961.5616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDISPEC        SE-1",
      "code_information": [
        {
          "code": "3012590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 341.6811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-RADIUS LOOP    R1010",
      "code_information": [
        {
          "code": "3012596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 6.5\\\" 0014M",
      "code_information": [
        {
          "code": "3012611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.6777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-TEFLON 6 1/2 BLADE",
      "code_information": [
        {
          "code": "3012613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDCAP-ROUND X-CORE    5960200",
      "code_information": [
        {
          "code": "3012635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4702,
          "minimum": 987.42,
          "maximum": 3442.8044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2926.3837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3012680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2877,
          "minimum": 604.17,
          "maximum": 2106.5394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1790.5585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVACUATOR-UROVAC       730-125",
      "code_information": [
        {
          "code": "3012699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVAC-SAF-T-VAC         ST9000S",
      "code_information": [
        {
          "code": "3012723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.0266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-GLUE             540133500",
      "code_information": [
        {
          "code": "3012805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXCISOR-BIOPSY CONE",
      "code_information": [
        {
          "code": "3012815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-DIALYSIS CATH  415612",
      "code_information": [
        {
          "code": "3012854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1265,
          "minimum": 265.65,
          "maximum": 926.233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 787.298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTRACTOR-TRIGEN DISP 71631320",
      "code_information": [
        {
          "code": "3012895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.8152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBE-VIPERSLIDE VPR-SLD2",
      "code_information": [
        {
          "code": "3012925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 1X6        007976",
      "code_information": [
        {
          "code": "3012991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.3213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 4\\\"X4\\\"       007836",
      "code_information": [
        {
          "code": "3012993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2074,
          "minimum": 435.54,
          "maximum": 1518.5828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1290.7954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 200M",
      "code_information": [
        {
          "code": "3013060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2420,
          "minimum": 508.2,
          "maximum": 1771.924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1506.1354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 365M",
      "code_information": [
        {
          "code": "3013061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2010,
          "minimum": 422.1,
          "maximum": 1471.722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1250.9637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 550M",
      "code_information": [
        {
          "code": "3013062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2649,
          "minimum": 556.29,
          "maximum": 1939.5978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1648.6581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 1000M",
      "code_information": [
        {
          "code": "3013063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3743,
          "minimum": 786.03,
          "maximum": 2740.6246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2329.5309,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-COUDE HEYMAN   021300",
      "code_information": [
        {
          "code": "3013087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1917,
          "minimum": 402.57,
          "maximum": 1403.6274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1193.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-HEYMAN         021100",
      "code_information": [
        {
          "code": "3013090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1718,
          "minimum": 360.78,
          "maximum": 1257.9196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1069.2317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPER-          AR-7237-7",
      "code_information": [
        {
          "code": "3013107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 3  AR-7227-01",
      "code_information": [
        {
          "code": "3013134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 204.7597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 4  AR-7230-01",
      "code_information": [
        {
          "code": "3013135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.6756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-HEPA BACTERIA 00182",
      "code_information": [
        {
          "code": "3013160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PED OXYKID W/7' TUBING",
      "code_information": [
        {
          "code": "3013161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-INSUFFLATION BULB",
      "code_information": [
        {
          "code": "3013164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.6423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP     1599-05",
      "code_information": [
        {
          "code": "3013203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 237,
          "minimum": 49.77,
          "maximum": 173.5314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.5017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-PIRANHA 3FR     505-160",
      "code_information": [
        {
          "code": "3013317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2055,
          "minimum": 431.55,
          "maximum": 1504.671,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1278.9704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW      000300s",
      "code_information": [
        {
          "code": "3013320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RJ4 LC BIOPSY 160CM",
      "code_information": [
        {
          "code": "3013323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.6423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GEL-PROLARYN          8602M0K5",
      "code_information": [
        {
          "code": "3013462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4034,
          "minimum": 847.14,
          "maximum": 2953.6948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2510.6406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3014234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 624.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 6.5 DRILL",
      "code_information": [
        {
          "code": "3014235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-AR-8737-01",
      "code_information": [
        {
          "code": "3014239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3014272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-DBX MIX 2.5CC     058025",
      "code_information": [
        {
          "code": "3014900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2432,
          "minimum": 510.72,
          "maximum": 1780.7104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1513.6038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-WIRE .035      WS-0906ST",
      "code_information": [
        {
          "code": "3016121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2MM           292.65",
      "code_information": [
        {
          "code": "3016129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 552,
          "minimum": 115.92,
          "maximum": 404.1744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 343.5482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0MM 702460",
      "code_information": [
        {
          "code": "3016131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K SMOOTH TIP AGK16100",
      "code_information": [
        {
          "code": "3016134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-3.2       03.010.115",
      "code_information": [
        {
          "code": "3016135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1091,
          "minimum": 229.11,
          "maximum": 798.8302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 679.0057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K W/OLIVE STOP",
      "code_information": [
        {
          "code": "3016136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 877.5417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-SUT GABBY-FRATER SUT 013",
      "code_information": [
        {
          "code": "3016153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.2636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDETHREAD 150MM  292.72",
      "code_information": [
        {
          "code": "3016158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 461,
          "minimum": 96.81,
          "maximum": 337.5442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 286.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP AR894301",
      "code_information": [
        {
          "code": "3016164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-HALTER DISP 08143101",
      "code_information": [
        {
          "code": "3016272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 118,
          "minimum": 24.78,
          "maximum": 86.3996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 73.4397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ADHESIVE 4\\\" WHITE",
      "code_information": [
        {
          "code": "3016326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1963",
      "code_information": [
        {
          "code": "3016347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1292,
          "minimum": 271.32,
          "maximum": 946.0024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 804.102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOVAC-400ML LG   2550-004-10",
      "code_information": [
        {
          "code": "3016381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.2082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-HYDRODEB     1914001",
      "code_information": [
        {
          "code": "3016387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2186,
          "minimum": 459.06,
          "maximum": 1600.5892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1360.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM SNGL PK 33508G",
      "code_information": [
        {
          "code": "3016420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM DOUBLE  3384-4",
      "code_information": [
        {
          "code": "3016425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 434,
          "minimum": 91.14,
          "maximum": 317.7748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 270.1086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 2X4 2082",
      "code_information": [
        {
          "code": "3016450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.3213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 4X4 2083",
      "code_information": [
        {
          "code": "3016451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1255,
          "minimum": 263.55,
          "maximum": 918.911,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 781.0743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-J CAUTERY     60-5272-232",
      "code_information": [
        {
          "code": "3016500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-ULTRASLING III XLG",
      "code_information": [
        {
          "code": "3017486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.8638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUTTLE-ACCU PASS SUTURE 70DEG",
      "code_information": [
        {
          "code": "3019705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1334,
          "minimum": 280.14,
          "maximum": 976.7548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 830.2416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-EVERGRIP LF  EVERGRIP61",
      "code_information": [
        {
          "code": "3019748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 200.4031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FDG",
      "code_information": [
        {
          "code": "3019810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2674,
          "minimum": 561.54,
          "maximum": 1957.9028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1664.2174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGL",
      "code_information": [
        {
          "code": "3019813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2674,
          "minimum": 561.54,
          "maximum": 1957.9028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1664.2174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGD",
      "code_information": [
        {
          "code": "3019815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3010,
          "minimum": 632.1,
          "maximum": 2203.922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1873.3337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-PEELAWAY 16F",
      "code_information": [
        {
          "code": "3019878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 615,
          "minimum": 129.15,
          "maximum": 450.303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 382.7575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT 9FR 3 1/2 PI93",
      "code_information": [
        {
          "code": "3019879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 381,
          "minimum": 80.01,
          "maximum": 278.9682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP NICU HNICU37",
      "code_information": [
        {
          "code": "3019903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2MM 500373",
      "code_information": [
        {
          "code": "3020202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 709,
          "minimum": 148.89,
          "maximum": 519.1298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.2603,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPER DISTRACTOR FF904SB",
      "code_information": [
        {
          "code": "3020203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1060,
          "minimum": 222.6,
          "maximum": 776.132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 659.7122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 17L 96550",
      "code_information": [
        {
          "code": "3020800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 515,
          "minimum": 108.15,
          "maximum": 377.083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 320.5206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-I RING PUPIL 587000",
      "code_information": [
        {
          "code": "3020804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1251,
          "minimum": 262.71,
          "maximum": 915.9822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 778.5849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL VISULIZATION",
      "code_information": [
        {
          "code": "3020806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUG 03.804.522S",
      "code_information": [
        {
          "code": "3020807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 859,
          "minimum": 180.39,
          "maximum": 628.9598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 534.6158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SCOPE WARMER TM500",
      "code_information": [
        {
          "code": "3020808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.4817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENTI SCAN IV DISP 177-092",
      "code_information": [
        {
          "code": "3020810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 451,
          "minimum": 94.71,
          "maximum": 330.2222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.6889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESSORY 700     72401850",
      "code_information": [
        {
          "code": "3020811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5472,
          "minimum": 1149.12,
          "maximum": 4006.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3405.6086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COAG  CSP208",
      "code_information": [
        {
          "code": "3020850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DILATOR NVM5       2029950",
      "code_information": [
        {
          "code": "3020915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2984.2641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-19",
      "code_information": [
        {
          "code": "3020920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-21",
      "code_information": [
        {
          "code": "3020922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2245,
          "minimum": 471.45,
          "maximum": 1643.789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1397.2206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC     96530-017",
      "code_information": [
        {
          "code": "3020928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 732.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IV MAXCESS         3240060",
      "code_information": [
        {
          "code": "3020969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8227,
          "minimum": 1727.67,
          "maximum": 6023.8094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5120.238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX PT STARTER  50-0071",
      "code_information": [
        {
          "code": "3021029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.6049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHUNT NONINVASIVE  9733605",
      "code_information": [
        {
          "code": "3021032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3599,
          "minimum": 755.79,
          "maximum": 2635.1878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2239.9096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 4ML 1501262",
      "code_information": [
        {
          "code": "3021034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1002.0157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH&BOOT 3550-80",
      "code_information": [
        {
          "code": "3021046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 476,
          "minimum": 99.96,
          "maximum": 348.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.2481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERITONEAL DIALYSIS 278006",
      "code_information": [
        {
          "code": "3021065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.7255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHOULDER CANNULA 5CM  9718",
      "code_information": [
        {
          "code": "3021080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.67,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-URO MAX HI PRESURE 225-136",
      "code_information": [
        {
          "code": "3021090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1753,
          "minimum": 368.13,
          "maximum": 1283.5466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1091.0146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXTRACTION GTG14",
      "code_information": [
        {
          "code": "3021113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4570,
          "minimum": 959.7,
          "maximum": 3346.154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2844.2309,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X12MM 663812",
      "code_information": [
        {
          "code": "3021130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 951,
          "minimum": 199.71,
          "maximum": 696.3222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 591.8739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CRESCENT         74-1010",
      "code_information": [
        {
          "code": "3021150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.3068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE,SLIT 2.4MM 45 DEGREE",
      "code_information": [
        {
          "code": "3021161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 163.6833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-GRAFT ACL 10MM    232110",
      "code_information": [
        {
          "code": "3021173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2004,
          "minimum": 420.84,
          "maximum": 1467.3288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1247.2295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT CLEAR CUT 2.4",
      "code_information": [
        {
          "code": "3021199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 303.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDE PORT 1.1    78-2010",
      "code_information": [
        {
          "code": "3021203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-TUIP             880-217",
      "code_information": [
        {
          "code": "3021220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 749,
          "minimum": 157.29,
          "maximum": 548.4178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 466.1551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE ALL AR-4000Ss",
      "code_information": [
        {
          "code": "3021225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE         AR-4068's",
      "code_information": [
        {
          "code": "3021227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 909.9049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDEPORT SAFETY 1.0MM",
      "code_information": [
        {
          "code": "3021241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.6479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINER-SZ25/36MM RL 12-105995",
      "code_information": [
        {
          "code": "3021635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4400,
          "minimum": 924,
          "maximum": 3221.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2738.428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-IMPACT         LF4318",
      "code_information": [
        {
          "code": "3021733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2708,
          "minimum": 568.68,
          "maximum": 1982.7976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1685.378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-DRAINAGE LOCKABLE 50-7245",
      "code_information": [
        {
          "code": "3021737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 162.4386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 26FR      880-214",
      "code_information": [
        {
          "code": "3021821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.9248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-DISPOSA ALL",
      "code_information": [
        {
          "code": "3021826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-ELECTRODE 24FR   WA22037C",
      "code_information": [
        {
          "code": "3021880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1483,
          "minimum": 311.43,
          "maximum": 1085.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 922.9747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WIRE SNARE 8-14515",
      "code_information": [
        {
          "code": "3021881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 365.3312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-MS SSEP NEEDLE  8050315",
      "code_information": [
        {
          "code": "3022945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5246,
          "minimum": 1101.66,
          "maximum": 3841.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3264.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE MEP/EMG",
      "code_information": [
        {
          "code": "3022955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3159.7725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SINGLE PORT PAL 240LS",
      "code_information": [
        {
          "code": "3023177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 495.4065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY STEALTH  9733068",
      "code_information": [
        {
          "code": "3027284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4784,
          "minimum": 1004.64,
          "maximum": 3502.8448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2977.4181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY TRU CUT 2N2700s",
      "code_information": [
        {
          "code": "3027285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 131.9424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY CUT      4418-16",
      "code_information": [
        {
          "code": "3027295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DEFLUX 23GX3.7FX350mm",
      "code_information": [
        {
          "code": "3027296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 744,
          "minimum": 156.24,
          "maximum": 544.7568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 463.0433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DISP INSUF      S100000",
      "code_information": [
        {
          "code": "3027310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 482,
          "minimum": 101.22,
          "maximum": 352.9204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 299.9823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ELECTRODE COATD E1465-6",
      "code_information": [
        {
          "code": "3027313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ENDOPATH INSUFF   PN120",
      "code_information": [
        {
          "code": "3027315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 719,
          "minimum": 150.99,
          "maximum": 526.4518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 447.484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL       105-1314",
      "code_information": [
        {
          "code": "3027318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-20      G00013",
      "code_information": [
        {
          "code": "3027330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FORAMEN 20G      041829",
      "code_information": [
        {
          "code": "3027344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 258.2835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-6 DJ6011X",
      "code_information": [
        {
          "code": "3027346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 292,
          "minimum": 61.32,
          "maximum": 213.8024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 181.732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR        1650050",
      "code_information": [
        {
          "code": "3027347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 390,
          "minimum": 81.9,
          "maximum": 285.558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 242.7243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSULATED EDGE   E1465B",
      "code_information": [
        {
          "code": "3027368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.6556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TR-CRON 2-0 STR W/10 SW",
      "code_information": [
        {
          "code": "3027402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 271.9757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR W/SHEATH",
      "code_information": [
        {
          "code": "3027403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 626,
          "minimum": 131.46,
          "maximum": 458.3572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 389.6036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OPUS SPEEDSTITCH",
      "code_information": [
        {
          "code": "3027425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 397,
          "minimum": 83.37,
          "maximum": 290.6834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 247.0809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OCTRODE 6\\\"         1116",
      "code_information": [
        {
          "code": "3027430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODESSECTION   N103A",
      "code_information": [
        {
          "code": "3027433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 690,
          "minimum": 144.9,
          "maximum": 505.218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 429.4353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION      AR-13991N",
      "code_information": [
        {
          "code": "3027443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 909.9049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SIDEKICK 21GA 14.6\\\"",
      "code_information": [
        {
          "code": "3027445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 793,
          "minimum": 166.53,
          "maximum": 580.6346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 493.5394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODISSECTION   E1xxx",
      "code_information": [
        {
          "code": "3027520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 795,
          "minimum": 166.95,
          "maximum": 582.099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 494.7842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-W/BASEPLATE BSDN-18-7.0",
      "code_information": [
        {
          "code": "3027587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 5MM  VS101005",
      "code_information": [
        {
          "code": "3027591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1299,
          "minimum": 272.79,
          "maximum": 951.1278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 808.4586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VERSASTEP 14GA VS150000",
      "code_information": [
        {
          "code": "3027593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 600,
          "minimum": 126,
          "maximum": 439.32,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 373.422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TROCAR 12MM VS101000s",
      "code_information": [
        {
          "code": "3027595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1224,
          "minimum": 257.04,
          "maximum": 896.2128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 761.7809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-WILSON PENILE IMPLANT",
      "code_information": [
        {
          "code": "3029175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2504,
          "minimum": 525.84,
          "maximum": 1833.4288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1558.4145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FENWAL TRANSFER 4R2014",
      "code_information": [
        {
          "code": "3029199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.4817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-EXTREMITY      DYNJ31779F",
      "code_information": [
        {
          "code": "3029200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 671,
          "minimum": 140.91,
          "maximum": 491.3062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 417.6103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAGNETIC DRAPE    31140562",
      "code_information": [
        {
          "code": "3029201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.6423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY ELITE VIAL     LC3001",
      "code_information": [
        {
          "code": "3029202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3536,
          "minimum": 742.56,
          "maximum": 2589.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2200.7003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SENSA TRAC M8275057/10",
      "code_information": [
        {
          "code": "3029214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-PERFUSION CUSTOM  CK0226R",
      "code_information": [
        {
          "code": "3029252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3994,
          "minimum": 838.74,
          "maximum": 2924.4068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2485.7458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SHOULDER ARTHROSCOP 29367",
      "code_information": [
        {
          "code": "3029266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 162.4386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SINUS KENNEDY      400422",
      "code_information": [
        {
          "code": "3029267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-TOTAL JOINT    DYNJ31778A",
      "code_information": [
        {
          "code": "3029268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM     440400",
      "code_information": [
        {
          "code": "3029278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HAND DYNJ52365",
      "code_information": [
        {
          "code": "3029301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 636,
          "minimum": 133.56,
          "maximum": 465.6792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 395.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VITRECTOMY CENTURION",
      "code_information": [
        {
          "code": "3029308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH  82-151x",
      "code_information": [
        {
          "code": "3029345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1307,
          "minimum": 274.47,
          "maximum": 956.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 813.4376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SMART STITCH PERFECT",
      "code_information": [
        {
          "code": "3029347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 917,
          "minimum": 192.57,
          "maximum": 671.4274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 570.7133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE           032401",
      "code_information": [
        {
          "code": "3029348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE LF 022701",
      "code_information": [
        {
          "code": "3029356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 713,
          "minimum": 149.73,
          "maximum": 522.0586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 443.7498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-HEMA KNITTED   HGK75/75P",
      "code_information": [
        {
          "code": "3029426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1254,
          "minimum": 263.34,
          "maximum": 918.1788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 780.452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-ACTIVA 2.5 INTELLIDOSE",
      "code_information": [
        {
          "code": "3029528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.4884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-DISPOSABLE  26-1221",
      "code_information": [
        {
          "code": "3029529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1666.7069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORIENTATION 2307-71-000",
      "code_information": [
        {
          "code": "3029762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-NAVIGATION 6007-003-150",
      "code_information": [
        {
          "code": "3029767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 581.9159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ARM ELEVATION 79-90500",
      "code_information": [
        {
          "code": "3029771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KNEE PROCEDURE TRACK 10712",
      "code_information": [
        {
          "code": "3029811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-DEMAYO LEG 110550",
      "code_information": [
        {
          "code": "3029813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BREAKAWAY GUIDE 2.5MM",
      "code_information": [
        {
          "code": "3029840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2605,
          "minimum": 547.05,
          "maximum": 1907.381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1621.2739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144110",
      "code_information": [
        {
          "code": "3029841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1086,
          "minimum": 228.06,
          "maximum": 795.1692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 675.8938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DHS GUIDE          900.723",
      "code_information": [
        {
          "code": "3029855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 658,
          "minimum": 138.18,
          "maximum": 481.7876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 409.5195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-POSITIONING EZ CLIP 2MM",
      "code_information": [
        {
          "code": "3029858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 698.9215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-FLUTED HEADLESS 7650-2038A",
      "code_information": [
        {
          "code": "3029885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1881,
          "minimum": 395.01,
          "maximum": 1377.2682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1170.678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE              357.399",
      "code_information": [
        {
          "code": "3029929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1109,
          "minimum": 232.89,
          "maximum": 812.0098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 690.2083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PINS-GUIDE 7.3         900.726",
      "code_information": [
        {
          "code": "3030050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 943,
          "minimum": 198.03,
          "maximum": 690.4646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 586.8949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z463G",
      "code_information": [
        {
          "code": "3032618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1\\\"",
      "code_information": [
        {
          "code": "3033301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 48,
          "minimum": 10.08,
          "maximum": 35.1456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 29.8738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 16FR 10ML",
      "code_information": [
        {
          "code": "3033303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F SCREWS 45-80040",
      "code_information": [
        {
          "code": "3033883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 909.9049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-LARGE SOFT       PCP40",
      "code_information": [
        {
          "code": "3033952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POINTER-TRACER         9733423",
      "code_information": [
        {
          "code": "3034140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3396,
          "minimum": 713.16,
          "maximum": 2486.5512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2113.5685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-BIOPSY             AUR-BP",
      "code_information": [
        {
          "code": "3034190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 316,
          "minimum": 66.36,
          "maximum": 231.3752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.6689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-GEL HAND            C8XX2",
      "code_information": [
        {
          "code": "3034194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2457.7391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOCATCH-II W/POUCH ALL 173's",
      "code_information": [
        {
          "code": "3034302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2140,
          "minimum": 449.4,
          "maximum": 1566.908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1331.8718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD ENTERAL 7FR 350CM",
      "code_information": [
        {
          "code": "3034510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NEUROVISION M5   2012021",
      "code_information": [
        {
          "code": "3034522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PIGTAIL 28-0174",
      "code_information": [
        {
          "code": "3034526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 662.824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LAPAROSCOPIC 5MM  160655",
      "code_information": [
        {
          "code": "3034572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 716.3479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 2.3MM 6.9FR 300CM",
      "code_information": [
        {
          "code": "3034891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-WOUND GELPOINT CNGL2",
      "code_information": [
        {
          "code": "3038330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2633.2475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-PAIN ONQ 400ML    PM028-A",
      "code_information": [
        {
          "code": "3038635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1884,
          "minimum": 395.64,
          "maximum": 1379.4648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1172.5451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-KNOT 2-0 FIBERWIRE",
      "code_information": [
        {
          "code": "3038667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-DEKNATEL 4.4      MDP-44",
      "code_information": [
        {
          "code": "3038930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 398,
          "minimum": 83.58,
          "maximum": 291.4156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 247.7033,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GREEN    ECR45G",
      "code_information": [
        {
          "code": "3039881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1406,
          "minimum": 295.26,
          "maximum": 1029.4732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 875.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO LINEAR       TR35B",
      "code_information": [
        {
          "code": "3039888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 838,
          "minimum": 175.98,
          "maximum": 613.5836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 521.5461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-TUBING         RF10210",
      "code_information": [
        {
          "code": "3039889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W564",
      "code_information": [
        {
          "code": "3039894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W332",
      "code_information": [
        {
          "code": "3039896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN        XR30G",
      "code_information": [
        {
          "code": "3039899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.2415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH       170056",
      "code_information": [
        {
          "code": "3039902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 536.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-VASCULAR/THIN     TR45W",
      "code_information": [
        {
          "code": "3039909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 756.8019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM              XR30B",
      "code_information": [
        {
          "code": "3039911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.2415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STANDARD BLUE     6R45B",
      "code_information": [
        {
          "code": "3039912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 756.8019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40B",
      "code_information": [
        {
          "code": "3039913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1699,
          "minimum": 356.79,
          "maximum": 1244.0078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1057.4066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD- STAPLE TCR-55",
      "code_information": [
        {
          "code": "3039914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 499,
          "minimum": 104.79,
          "maximum": 365.3678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 310.5626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-LINEAR CUTTER    TCR-75",
      "code_information": [
        {
          "code": "3039916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 820,
          "minimum": 172.2,
          "maximum": 600.404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40G",
      "code_information": [
        {
          "code": "3039917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1699,
          "minimum": 356.79,
          "maximum": 1244.0078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1057.4066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER    TCT75",
      "code_information": [
        {
          "code": "3039918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1465,
          "minimum": 307.65,
          "maximum": 1072.673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 911.772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM BLUE         XR60B",
      "code_information": [
        {
          "code": "3039920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 514,
          "minimum": 107.94,
          "maximum": 376.3508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO GIA 30/3.5  030452",
      "code_information": [
        {
          "code": "3039932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2061,
          "minimum": 432.81,
          "maximum": 1509.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.7046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-CARIOTOMY        205",
      "code_information": [
        {
          "code": "3039975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 465,
          "minimum": 97.65,
          "maximum": 340.473,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 289.402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-DISP FILTRA 04259",
      "code_information": [
        {
          "code": "3039981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 364.0865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-OMMAYA    NL850-121x",
      "code_information": [
        {
          "code": "3040439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3043,
          "minimum": 639.03,
          "maximum": 2228.0846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1893.8719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD UNIV     050602",
      "code_information": [
        {
          "code": "3040461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 190.4452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-C-SECTION DISP G6314",
      "code_information": [
        {
          "code": "3040500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 512.8329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND          C8404",
      "code_information": [
        {
          "code": "3040501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 512.8329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEXOR TENDON",
      "code_information": [
        {
          "code": "3040509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1666.7069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-LONESTAR        3304",
      "code_information": [
        {
          "code": "3040511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1080,
          "minimum": 226.8,
          "maximum": 790.776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 672.1596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ORTHO ALEXIS   HR004",
      "code_information": [
        {
          "code": "3040513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1611,
          "minimum": 338.31,
          "maximum": 1179.5742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1002.6381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE        013593",
      "code_information": [
        {
          "code": "3040518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 558,
          "minimum": 117.18,
          "maximum": 408.5676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.2825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-SURGICAL RING   3715",
      "code_information": [
        {
          "code": "3040521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1370,
          "minimum": 287.7,
          "maximum": 1003.114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 852.6469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-LOOPED 3 PRONG  5030",
      "code_information": [
        {
          "code": "3040525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 464.9104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND LG       C8303",
      "code_information": [
        {
          "code": "3040527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND MEDIUM   C8302",
      "code_information": [
        {
          "code": "3040530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XL       C8304",
      "code_information": [
        {
          "code": "3040532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 512.8329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND SMALL    C8301",
      "code_information": [
        {
          "code": "3040533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XSMALL   C8312",
      "code_information": [
        {
          "code": "3040534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-MALYUGIN ALL SZS MAL-000x",
      "code_information": [
        {
          "code": "3040661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1565,
          "minimum": 328.65,
          "maximum": 1145.893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 974.0091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.8 CANN DRI",
      "code_information": [
        {
          "code": "3040704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-2.0X7          AR-7200S",
      "code_information": [
        {
          "code": "3044850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 514.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 2.3 BIPOLAR",
      "code_information": [
        {
          "code": "3044897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1733.3004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS MALLEABLE BI",
      "code_information": [
        {
          "code": "3044899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3215,
          "minimum": 675.15,
          "maximum": 2354.023,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2000.9195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION ANSPACH 111613",
      "code_information": [
        {
          "code": "3044922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 601.2094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCISSORS-ENDODUT METZ     3142",
      "code_information": [
        {
          "code": "3044930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 460,
          "minimum": 96.6,
          "maximum": 336.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 286.2902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68HP ALL",
      "code_information": [
        {
          "code": "3049715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY ALL 351-3000'sS",
      "code_information": [
        {
          "code": "3049750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRI PORT III PAL 303LS",
      "code_information": [
        {
          "code": "3050004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 4.0X170 144170",
      "code_information": [
        {
          "code": "3050009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 588.1396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CELLEBRITY CYTOLOGY",
      "code_information": [
        {
          "code": "3050015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 234,
          "minimum": 49.14,
          "maximum": 171.3348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 145.6346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATIR SM DISP 13MM",
      "code_information": [
        {
          "code": "3055843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 122.6069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 2ML 1506078",
      "code_information": [
        {
          "code": "3055845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1499,
          "minimum": 314.79,
          "maximum": 1097.5678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 932.9326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL ALL SZS 456.30Xs",
      "code_information": [
        {
          "code": "3055898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3677,
          "minimum": 772.17,
          "maximum": 2692.2994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2288.4545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MISTY NEB W/FILTER",
      "code_information": [
        {
          "code": "3058511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-HELIOCOIDAL RASP 3.2MM",
      "code_information": [
        {
          "code": "3058512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1092,
          "minimum": 229.32,
          "maximum": 799.5624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 679.628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONE MILL DISP",
      "code_information": [
        {
          "code": "3058513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1791,
          "minimum": 376.11,
          "maximum": 1311.3702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1114.6647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-CORE IRRIGATION",
      "code_information": [
        {
          "code": "3058514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 472,
          "minimum": 99.12,
          "maximum": 345.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 293.7586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 2.3MM",
      "code_information": [
        {
          "code": "3058515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1089,
          "minimum": 228.69,
          "maximum": 797.3658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.7609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-SOFT TOUCH RND FLUTED ALL",
      "code_information": [
        {
          "code": "3058516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND ALL SIZES",
      "code_information": [
        {
          "code": "3058517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 794.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND COURSE ALL",
      "code_information": [
        {
          "code": "3058518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 3.0MM",
      "code_information": [
        {
          "code": "3058521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1089,
          "minimum": 228.69,
          "maximum": 797.3658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.7609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CUTTING DIAMOND 25.4X0.8",
      "code_information": [
        {
          "code": "3058522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 648.5095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 310.23S",
      "code_information": [
        {
          "code": "3058526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1551,
          "minimum": 325.71,
          "maximum": 1135.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 965.2959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 02.7 CSS-072-27",
      "code_information": [
        {
          "code": "3058530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1347,
          "minimum": 282.87,
          "maximum": 986.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 838.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110 143110",
      "code_information": [
        {
          "code": "3058543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 683,
          "minimum": 143.43,
          "maximum": 500.0926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 425.0787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EPIDURAL 117\\\" INF 1633902",
      "code_information": [
        {
          "code": "3058611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.4673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE 10X5",
      "code_information": [
        {
          "code": "3058612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1239,
          "minimum": 260.19,
          "maximum": 907.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 771.1164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-FLOW 50 COBLATION",
      "code_information": [
        {
          "code": "3058620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1833,
          "minimum": 384.93,
          "maximum": 1342.1226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1140.8042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ACCOMINIZER 4.0",
      "code_information": [
        {
          "code": "3058623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 275.0875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STONCUTTER 5.5 7205331",
      "code_information": [
        {
          "code": "3058624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 956,
          "minimum": 200.76,
          "maximum": 699.9832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 594.9857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3058625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 ORBIT 7205323",
      "code_information": [
        {
          "code": "3058626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 396.4497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4.0 1864G",
      "code_information": [
        {
          "code": "3058639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL FLEX MED 27MM",
      "code_information": [
        {
          "code": "3058643",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.9779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-RETRIEVAL 30MM DGN-538-5",
      "code_information": [
        {
          "code": "3058644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 941,
          "minimum": 197.61,
          "maximum": 689.0002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 585.6502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I KNIFE SURG 8065921552",
      "code_information": [
        {
          "code": "3058653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.3699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 2.0MM 5820-010-020",
      "code_information": [
        {
          "code": "3058655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1105,
          "minimum": 232.05,
          "maximum": 809.081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 687.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDO FEEDING 12FR X 60”",
      "code_information": [
        {
          "code": "3058693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.2559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MINI 4.0 283459",
      "code_information": [
        {
          "code": "3058696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1275,
          "minimum": 267.75,
          "maximum": 933.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 793.5217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 FULL RADIUS",
      "code_information": [
        {
          "code": "3058697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1275,
          "minimum": 267.75,
          "maximum": 933.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 793.5217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3058698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 919,
          "minimum": 192.99,
          "maximum": 672.8918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 571.958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 018 14MMX34CM",
      "code_information": [
        {
          "code": "3058707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2633.2475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-240",
      "code_information": [
        {
          "code": "3058716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANOSCOPE-BEVELED DISP 103X18M",
      "code_information": [
        {
          "code": "3058720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-EXPEL NEPHR I/E 8.3/22",
      "code_information": [
        {
          "code": "3058729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1262,
          "minimum": 265.02,
          "maximum": 924.0364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 785.4309,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH 15FR 71C",
      "code_information": [
        {
          "code": "3058737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-VPAD 2 INS-0050",
      "code_information": [
        {
          "code": "3058749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2207,
          "minimum": 463.47,
          "maximum": 1615.9654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1373.5706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-ALWAYS ON TIP INS-0352",
      "code_information": [
        {
          "code": "3058751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1816.0757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-19 GA ANSO INS-0382",
      "code_information": [
        {
          "code": "3058752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1816.0757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GA ANSO INS 0392",
      "code_information": [
        {
          "code": "3058753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1816.0757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GA NITINOL INS-5410",
      "code_information": [
        {
          "code": "3058754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4175,
          "minimum": 876.75,
          "maximum": 3056.935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2598.3947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPINPERC INS-5600",
      "code_information": [
        {
          "code": "3058755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2207,
          "minimum": 463.47,
          "maximum": 1615.9654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1373.5706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE DISTRACTOR DISP",
      "code_information": [
        {
          "code": "3058766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 351.0167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE 1.5X36",
      "code_information": [
        {
          "code": "3058775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 AR 8943-16",
      "code_information": [
        {
          "code": "3058786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1013,
          "minimum": 212.73,
          "maximum": 741.7186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 630.4608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPIN EWC BIOPSY GUIDE",
      "code_information": [
        {
          "code": "3058788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3127,
          "minimum": 656.67,
          "maximum": 2289.5894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1946.151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DISP SHOULDER 1.8MM",
      "code_information": [
        {
          "code": "3058805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1659,
          "minimum": 348.39,
          "maximum": 1214.7198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1032.5118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENTRAINER-AIR RT008",
      "code_information": [
        {
          "code": "3058809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 5.0 5050",
      "code_information": [
        {
          "code": "3058819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58043,
          "minimum": 12189.03,
          "maximum": 42499.0846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36124.2219,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 7.0 7050",
      "code_information": [
        {
          "code": "3058820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60044,
          "minimum": 12609.24,
          "maximum": 43964.2168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37369.5843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 BV-1 M8709",
      "code_information": [
        {
          "code": "3058836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 464.9104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 2MMXxxCM",
      "code_information": [
        {
          "code": "3058843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4220,
          "minimum": 886.2,
          "maximum": 3089.884,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2626.4014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX20CM",
      "code_information": [
        {
          "code": "3058844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5064,
          "minimum": 1063.44,
          "maximum": 3707.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3151.6817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX30CM",
      "code_information": [
        {
          "code": "3058845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5591,
          "minimum": 1174.11,
          "maximum": 4093.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3479.6707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 CX ALL",
      "code_information": [
        {
          "code": "3058846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2633.2475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HEATED AIRVO 900PT501",
      "code_information": [
        {
          "code": "3058860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO SM OPT942",
      "code_information": [
        {
          "code": "3058861",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 203.515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO MED OPT944",
      "code_information": [
        {
          "code": "3058862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 203.515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO LARGE OPT946",
      "code_information": [
        {
          "code": "3058863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 203.515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-013-000 SZ4",
      "code_information": [
        {
          "code": "3058864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.4673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HEALING W/PLUG 30MM 95084",
      "code_information": [
        {
          "code": "3058868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 134.4319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN LITE FUD023",
      "code_information": [
        {
          "code": "3058869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.5MM",
      "code_information": [
        {
          "code": "3058875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CONTOUR CERVICAL 13-15",
      "code_information": [
        {
          "code": "3058876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-RIB UNIVERSAL 8” MALE",
      "code_information": [
        {
          "code": "3058877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3.0 1893G",
      "code_information": [
        {
          "code": "3058878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SLIM MED",
      "code_information": [
        {
          "code": "3058885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 145.0122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-SYSTEM UA2007",
      "code_information": [
        {
          "code": "3058887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 162,
          "minimum": 34.02,
          "maximum": 118.6164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.8239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WATER SUCTION BIOPSY VALVE",
      "code_information": [
        {
          "code": "3058903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.9081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-ACCUSTAT 125NM S 801015",
      "code_information": [
        {
          "code": "3058929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5081,
          "minimum": 1067.01,
          "maximum": 3720.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3162.262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MIDLINE 5FR BIO FLO",
      "code_information": [
        {
          "code": "3058932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 1.4X27MM",
      "code_information": [
        {
          "code": "3058955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3358,
          "minimum": 705.18,
          "maximum": 2458.7276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2089.9185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON,CAPIOX HPH-1000",
      "code_information": [
        {
          "code": "3058981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 530.2592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOBLADE GASTRO",
      "code_information": [
        {
          "code": "3058983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3142.3461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORTHOLOCK 3X110MM EX",
      "code_information": [
        {
          "code": "3058990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 581.9159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X 343MM",
      "code_information": [
        {
          "code": "3058991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1159,
          "minimum": 243.39,
          "maximum": 848.6198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 721.3268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y935H",
      "code_information": [
        {
          "code": "3059006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.0X40X91MM",
      "code_information": [
        {
          "code": "3059015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.7753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-GENESYS HTA M006580211",
      "code_information": [
        {
          "code": "3059026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6769,
          "minimum": 1421.49,
          "maximum": 4956.2618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4212.8225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-CLEANING STICK 900PT602",
      "code_information": [
        {
          "code": "3059061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-QUADFUSE 9” EXT SMALLBORE",
      "code_information": [
        {
          "code": "3059062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED OPT316",
      "code_information": [
        {
          "code": "3059066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 522,
          "minimum": 109.62,
          "maximum": 382.2084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 324.8771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PED 900PT531",
      "code_information": [
        {
          "code": "3059068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 722,
          "minimum": 151.62,
          "maximum": 528.6484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 449.3511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-ABSOLUTE PSI-TEC",
      "code_information": [
        {
          "code": "3059124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 213.4729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-HEADREST SOFTOUCH",
      "code_information": [
        {
          "code": "3059127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ESOPHYX TIF R2007",
      "code_information": [
        {
          "code": "3059129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21712,
          "minimum": 4559.52,
          "maximum": 15897.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13512.8974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTER CONNECT PT-5558-F",
      "code_information": [
        {
          "code": "3059131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 3.5X195 700353",
      "code_information": [
        {
          "code": "3059137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1228,
          "minimum": 257.88,
          "maximum": 899.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 764.2704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACQUIRE EUS FND",
      "code_information": [
        {
          "code": "3059156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 2.0MM BIT",
      "code_information": [
        {
          "code": "3059170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2114,
          "minimum": 443.94,
          "maximum": 1547.8708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1315.6902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-IMPLANT SIZING SG - x",
      "code_information": [
        {
          "code": "3059171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIALYZER-HIGH FLUX 1.6 720DH16",
      "code_information": [
        {
          "code": "3059177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.1805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ULTRAPERC FULL 100/573/000",
      "code_information": [
        {
          "code": "3059178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1545,
          "minimum": 324.45,
          "maximum": 1131.249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 961.5616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT MED",
      "code_information": [
        {
          "code": "3059179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.2304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENVEO PRO LOADING",
      "code_information": [
        {
          "code": "3059185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2618,
          "minimum": 549.78,
          "maximum": 1916.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1629.3647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 1.5MM NEEDLES",
      "code_information": [
        {
          "code": "3059187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 460,
          "minimum": 96.6,
          "maximum": 336.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 286.2902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN 5X5CM FUD021",
      "code_information": [
        {
          "code": "3059209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-KNOTLESS S-TAK STEP 3MM",
      "code_information": [
        {
          "code": "3059213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.7399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW OSC SAGITTAL xxMM",
      "code_information": [
        {
          "code": "3059220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 388.3589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO DURACLIP 235CM 11MM",
      "code_information": [
        {
          "code": "3059232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 877.5417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-HEEL PRESSURE MDT825",
      "code_information": [
        {
          "code": "3059240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT LG",
      "code_information": [
        {
          "code": "3059245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.2304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT SM",
      "code_information": [
        {
          "code": "3059246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.2304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-POLAR COMBO 1232PP",
      "code_information": [
        {
          "code": "3059252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 907,
          "minimum": 190.47,
          "maximum": 664.1054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 564.4896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-TRI STAPLE 2.0 SIG30AVM",
      "code_information": [
        {
          "code": "3059259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2871,
          "minimum": 602.91,
          "maximum": 2102.1462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1786.8243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND 1.0MM",
      "code_information": [
        {
          "code": "3059273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 794.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION LARGE",
      "code_information": [
        {
          "code": "3059275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.2846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION MED",
      "code_information": [
        {
          "code": "3059281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 279,
          "minimum": 58.59,
          "maximum": 204.2838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 15\\\" ADJ ILIO",
      "code_information": [
        {
          "code": "3059288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 328,
          "minimum": 68.88,
          "maximum": 240.1616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 204.1374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP ALL",
      "code_information": [
        {
          "code": "3059603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT 111645",
      "code_information": [
        {
          "code": "3059922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 484.8262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X140 143140",
      "code_information": [
        {
          "code": "3059924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1195,
          "minimum": 250.95,
          "maximum": 874.979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 743.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LIGASURE SM  LF1212A",
      "code_information": [
        {
          "code": "3059951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3010,
          "minimum": 632.1,
          "maximum": 2203.922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1873.3337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-LEVER EDGE    4100-01",
      "code_information": [
        {
          "code": "3059965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1454,
          "minimum": 305.34,
          "maximum": 1064.6188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 904.926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ABC SINGLE FUNCTION",
      "code_information": [
        {
          "code": "3059973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 529.0145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATCHER-STONE WITH TUB 840-750",
      "code_information": [
        {
          "code": "3059984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 825,
          "minimum": 173.25,
          "maximum": 604.065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 513.4552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP       7-382",
      "code_information": [
        {
          "code": "3059989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ISOLATOR  BIP   OSL2",
      "code_information": [
        {
          "code": "3059996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11959,
          "minimum": 2511.39,
          "maximum": 8756.3798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7442.9228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-LINEAR 60GRN      TX60G",
      "code_information": [
        {
          "code": "3060001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 913,
          "minimum": 191.73,
          "maximum": 668.4986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.2238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM GREEN        XR60G",
      "code_information": [
        {
          "code": "3060002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 550,
          "minimum": 115.5,
          "maximum": 402.71,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 342.3035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE   RC014MIBB",
      "code_information": [
        {
          "code": "3060082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 581.9159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CORONARY PERFUSN 10004",
      "code_information": [
        {
          "code": "3060083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEX IRIS     611.75",
      "code_information": [
        {
          "code": "3060129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 858,
          "minimum": 180.18,
          "maximum": 628.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 533.9935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 8\\\"  7708-000-10",
      "code_information": [
        {
          "code": "3060132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.0465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VESSEL           30003",
      "code_information": [
        {
          "code": "3060134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 101,
          "minimum": 21.21,
          "maximum": 73.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.8594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SWANSON SUTURE  11-0675",
      "code_information": [
        {
          "code": "3060151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 617.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-T-TUBE 16FR       0099830",
      "code_information": [
        {
          "code": "3060199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-RETRACTO 12\\\" 1041",
      "code_information": [
        {
          "code": "3060247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE MEDIUM   9893",
      "code_information": [
        {
          "code": "3060289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.9403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH      SZ5  A0A04",
      "code_information": [
        {
          "code": "3060306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 162.4386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-UNIV     60-6010-001",
      "code_information": [
        {
          "code": "3060315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.0798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERZ-REFLECTIVE PK   PM 8005",
      "code_information": [
        {
          "code": "3060317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-SPRING CLIP 6MM  CSOFT6",
      "code_information": [
        {
          "code": "3060318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.5715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-SILVERSTEIN PK 1428010",
      "code_information": [
        {
          "code": "3060385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.0753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0 CT-2 Z332H",
      "code_information": [
        {
          "code": "3060417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.7542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROGRAMMER-TEST STIM 3531",
      "code_information": [
        {
          "code": "3060442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2604,
          "minimum": 546.84,
          "maximum": 1906.6488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1620.6515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MINI HOOK 357501",
      "code_information": [
        {
          "code": "3060443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 290.0244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 4.0MM 03.000.012S",
      "code_information": [
        {
          "code": "3060451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 745,
          "minimum": 156.45,
          "maximum": 545.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 463.6656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 5.0MM 03.000.015S",
      "code_information": [
        {
          "code": "3060452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.0798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90X9.5 05.003.126S",
      "code_information": [
        {
          "code": "3060455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 388.3589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 10M",
      "code_information": [
        {
          "code": "3060460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3512,
          "minimum": 737.52,
          "maximum": 2571.4864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2185.7634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT",
      "code_information": [
        {
          "code": "3060472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 5MM PAL-508LL",
      "code_information": [
        {
          "code": "3060475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 460.5538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-FAST FIX 360 KPSC",
      "code_information": [
        {
          "code": "3060478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1344,
          "minimum": 282.24,
          "maximum": 984.0768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 836.4653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU RIGHT 7210424",
      "code_information": [
        {
          "code": "3060485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1334,
          "minimum": 280.14,
          "maximum": 976.7548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 830.2416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU LEFT 7210423",
      "code_information": [
        {
          "code": "3060486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STRT 7210426",
      "code_information": [
        {
          "code": "3060488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.3MM CROSSPIN 62-23333",
      "code_information": [
        {
          "code": "3060489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 909.9049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STR 7210425",
      "code_information": [
        {
          "code": "3060494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 779.8296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SILICONE 8CM        205108",
      "code_information": [
        {
          "code": "3061090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1750,
          "minimum": 367.5,
          "maximum": 1281.35,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1089.1475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-SINGLE HOLE 1877-01-010",
      "code_information": [
        {
          "code": "3062492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2040,
          "minimum": 428.4,
          "maximum": 1493.688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1269.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-3' EPV100 VENT",
      "code_information": [
        {
          "code": "3068320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX PEDS MAXP",
      "code_information": [
        {
          "code": "3068323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP VIBRATORY ACAPELLA",
      "code_information": [
        {
          "code": "3068325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 509,
          "minimum": 106.89,
          "maximum": 372.6898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.7863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED W/7' TUBING",
      "code_information": [
        {
          "code": "3068327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BIPAP PERFORMATRAK LARGE",
      "code_information": [
        {
          "code": "3068330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT DUAL LIMB",
      "code_information": [
        {
          "code": "3068331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT CAPNOXYGEN C02-01",
      "code_information": [
        {
          "code": "3068332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT/PED 8’ 58051",
      "code_information": [
        {
          "code": "3068333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.5161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-MYOSURE            40-902",
      "code_information": [
        {
          "code": "3078533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 171,
          "minimum": 35.91,
          "maximum": 125.2062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.4253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-DURA           20-xxxx",
      "code_information": [
        {
          "code": "3078541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5964,
          "minimum": 1252.44,
          "maximum": 4366.8408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3711.8147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-DURAL           1314",
      "code_information": [
        {
          "code": "3078593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH INDWELLING SLIT 295-6",
      "code_information": [
        {
          "code": "3078730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 972.1419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-KARLEN BALLOON    CS-01700",
      "code_information": [
        {
          "code": "3078823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML 0797208",
      "code_information": [
        {
          "code": "3078850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.7885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU, DIALYSIS 2.5% 2L 5B9876",
      "code_information": [
        {
          "code": "3078852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 497,
          "minimum": 104.37,
          "maximum": 363.9034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.3179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML  07138-09",
      "code_information": [
        {
          "code": "3078858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 51,
          "minimum": 10.71,
          "maximum": 37.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 31.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK E3773-45C",
      "code_information": [
        {
          "code": "3078982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1254,
          "minimum": 263.34,
          "maximum": 918.1788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 780.452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MAS TLIF LIGHT   3400033",
      "code_information": [
        {
          "code": "3079040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1775.6216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MULTILEAD TRIAL     3013",
      "code_information": [
        {
          "code": "3079055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1144,
          "minimum": 240.24,
          "maximum": 837.6368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 711.9913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.0X13        AR-8400EX",
      "code_information": [
        {
          "code": "3079215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 283.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.-X13 AR-8500EX",
      "code_information": [
        {
          "code": "3079228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 282.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER        20400161S/10",
      "code_information": [
        {
          "code": "3079240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 190.4452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL G2 TIP 35CM",
      "code_information": [
        {
          "code": "3079250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3329,
          "minimum": 699.09,
          "maximum": 2437.4938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2071.8697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 ABRADER    72201518",
      "code_information": [
        {
          "code": "3079252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 656,
          "minimum": 137.76,
          "maximum": 480.3232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.2747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR    72201513",
      "code_information": [
        {
          "code": "3079253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 396.4497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3079254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 372.1773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5 FULL RADIUS 7205305",
      "code_information": [
        {
          "code": "3079257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 283.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-4.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3079259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 FULL RADIUM 7205306",
      "code_information": [
        {
          "code": "3079261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 275.0875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 INCISOR     7205345",
      "code_information": [
        {
          "code": "3079262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 275.0875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL 45CM    NSLG2C45A",
      "code_information": [
        {
          "code": "3079282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3167,
          "minimum": 665.07,
          "maximum": 2318.8774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1971.0458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 36\\\"   HAR36",
      "code_information": [
        {
          "code": "3079285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3146,
          "minimum": 660.66,
          "maximum": 2303.5012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1957.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HS FOCUS 9CM CRVD  HAR9F",
      "code_information": [
        {
          "code": "3079290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2871,
          "minimum": 602.91,
          "maximum": 2102.1462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1786.8243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INPUT 8FR PS    080011",
      "code_information": [
        {
          "code": "3079468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.6357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNLER SM-LG    9009-s",
      "code_information": [
        {
          "code": "3079475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 766,
          "minimum": 160.86,
          "maximum": 560.8652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 476.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-RENAL 20CM      900-123",
      "code_information": [
        {
          "code": "3079482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.8638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-EXT BILATERAL DYNJP8004A",
      "code_information": [
        {
          "code": "3079499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-CORNEAL DISP      E5699",
      "code_information": [
        {
          "code": "3079626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.5936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST-OP XL MALE      1315",
      "code_information": [
        {
          "code": "3079661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909504",
      "code_information": [
        {
          "code": "3079703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11962,
          "minimum": 2512.02,
          "maximum": 8758.5764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7444.7899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5070",
      "code_information": [
        {
          "code": "3079707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3761,
          "minimum": 789.81,
          "maximum": 2753.8042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2340.7336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5071",
      "code_information": [
        {
          "code": "3079709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3761,
          "minimum": 789.81,
          "maximum": 2753.8042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2340.7336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PHACO .9MM  8065-750517",
      "code_information": [
        {
          "code": "3079736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 429,
          "minimum": 90.09,
          "maximum": 314.1138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 266.9967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SMALL VIT PLUS 1",
      "code_information": [
        {
          "code": "3079745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1675,
          "minimum": 351.75,
          "maximum": 1226.435,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1042.4697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STAR            AR-1606",
      "code_information": [
        {
          "code": "3079766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 877,
          "minimum": 184.17,
          "maximum": 642.1394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 545.8185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 12MM        CB12LT",
      "code_information": [
        {
          "code": "3079770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1106,
          "minimum": 232.26,
          "maximum": 809.8132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 688.3412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM KII          CFS22",
      "code_information": [
        {
          "code": "3079789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.2082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-FIBER          AR-7209SN",
      "code_information": [
        {
          "code": "3079790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.7399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM KII           CFS02",
      "code_information": [
        {
          "code": "3079791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM THREADED KII CTS22",
      "code_information": [
        {
          "code": "3079792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.2082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM THREADED KII  CTS0S",
      "code_information": [
        {
          "code": "3079793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.1108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATABLE OVAL",
      "code_information": [
        {
          "code": "3079795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 297,
          "minimum": 62.37,
          "maximum": 217.4634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.8439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SILICONE         400561",
      "code_information": [
        {
          "code": "3079975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 550,
          "minimum": 115.5,
          "maximum": 402.71,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 342.3035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER MINI        1500",
      "code_information": [
        {
          "code": "3079992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 365.3312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER SMALL       1500",
      "code_information": [
        {
          "code": "3079994",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 554,
          "minimum": 116.34,
          "maximum": 405.6388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 344.793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER PETITE      1500",
      "code_information": [
        {
          "code": "3079996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 365.3312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-AGGRESSIVE 3.5   283315",
      "code_information": [
        {
          "code": "3080062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 356.618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ULTRA AGGRESSIVE 283325",
      "code_information": [
        {
          "code": "3080067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 356.618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.5MM AR-1204AS-95",
      "code_information": [
        {
          "code": "3080073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2182,
          "minimum": 458.22,
          "maximum": 1597.6604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1358.0113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 10MM AR-1204AS-100",
      "code_information": [
        {
          "code": "3080074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1357.389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.0MM AR1204AS90",
      "code_information": [
        {
          "code": "3080075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1819,
          "minimum": 381.99,
          "maximum": 1331.8718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1132.091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-OPTIMOLD NASAL   PS1688",
      "code_information": [
        {
          "code": "3080204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.9291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3080355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 352,
          "minimum": 73.92,
          "maximum": 257.7344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 219.0742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-EGIA 60 MED   EGIA60AVM",
      "code_information": [
        {
          "code": "3080925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-ENDOCLIP MULTI    ER320",
      "code_information": [
        {
          "code": "3080932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 859,
          "minimum": 180.39,
          "maximum": 628.9598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 534.6158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR VASCULAR  TX30V",
      "code_information": [
        {
          "code": "3081085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.0976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT 12”",
      "code_information": [
        {
          "code": "3081101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.4884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT RIGHT",
      "code_information": [
        {
          "code": "3081102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.4884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY RT ANGLE Y PORT 12”",
      "code_information": [
        {
          "code": "3081103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.4884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL HEALTHVENT 24HR 97021",
      "code_information": [
        {
          "code": "3081122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 131.9424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIEDER TS101DC",
      "code_information": [
        {
          "code": "3081129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 594,
          "minimum": 124.74,
          "maximum": 434.9268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 369.6878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-POLYSORB 55      SZ 200",
      "code_information": [
        {
          "code": "3081173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4940,
          "minimum": 1037.4,
          "maximum": 3617.068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3074.5078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN INSORB 2030",
      "code_information": [
        {
          "code": "3081400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 894,
          "minimum": 187.74,
          "maximum": 654.5868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 556.3988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZS ECS's",
      "code_information": [
        {
          "code": "3081408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1763,
          "minimum": 370.23,
          "maximum": 1290.8686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1097.2383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZ CDHxxA",
      "code_information": [
        {
          "code": "3081415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1570,
          "minimum": 329.7,
          "maximum": 1149.554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 977.1209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWER  PLEE60A",
      "code_information": [
        {
          "code": "3081416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2611,
          "minimum": 548.31,
          "maximum": 1911.7742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1625.0081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWERED PCE60A",
      "code_information": [
        {
          "code": "3081432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2475,
          "minimum": 519.75,
          "maximum": 1812.195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1540.3657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 45       EC45A",
      "code_information": [
        {
          "code": "3081433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2038,
          "minimum": 427.98,
          "maximum": 1492.2236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1268.3901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 60       EC60A",
      "code_information": [
        {
          "code": "3081436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2635,
          "minimum": 553.35,
          "maximum": 1929.347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1639.9449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-EGIA HANDLE  EGIAUSTND",
      "code_information": [
        {
          "code": "3081443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2985,
          "minimum": 626.85,
          "maximum": 2185.617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1857.7744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDO GIA UNIVER 030449",
      "code_information": [
        {
          "code": "3081491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1643.0568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-THICK TISSUE      TRT75",
      "code_information": [
        {
          "code": "3081494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3081502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT STR 35WD",
      "code_information": [
        {
          "code": "3081503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAYS-SURGICAL PACK    3311-8G",
      "code_information": [
        {
          "code": "3081506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER   TLC-75",
      "code_information": [
        {
          "code": "3081530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 60BL      TX60B",
      "code_information": [
        {
          "code": "3081535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 562.6225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR  40B     CS40B",
      "code_information": [
        {
          "code": "3081542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3019,
          "minimum": 633.99,
          "maximum": 2210.5118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1878.935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40G      CS40G",
      "code_information": [
        {
          "code": "3081544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3019,
          "minimum": 633.99,
          "maximum": 2210.5118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1878.935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDOPATH VASC PVE35A",
      "code_information": [
        {
          "code": "3081550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2231,
          "minimum": 468.51,
          "maximum": 1633.5382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1388.5075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-HEAVY WIRE 90    TLH90",
      "code_information": [
        {
          "code": "3081554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 791,
          "minimum": 166.11,
          "maximum": 579.1702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 492.2947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3081569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.6357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A28-2",
      "code_information": [
        {
          "code": "3082047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21603,
          "minimum": 4536.63,
          "maximum": 15817.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13445.0591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A25-25",
      "code_information": [
        {
          "code": "3082066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21603,
          "minimum": 4536.63,
          "maximum": 15817.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13445.0591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-AAA MAIN    ETCF3636C49E",
      "code_information": [
        {
          "code": "3082068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20042,
          "minimum": 4208.82,
          "maximum": 14674.7524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 12473.5395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STICK-FIBER            AR-7209",
      "code_information": [
        {
          "code": "3082089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKINETTE-BARRIER   NON22535",
      "code_information": [
        {
          "code": "3082135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE FOOT        014407",
      "code_information": [
        {
          "code": "3082217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 659,
          "minimum": 138.39,
          "maximum": 482.5198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 410.1418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRAIGHT           1123",
      "code_information": [
        {
          "code": "3082330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUMP-PERICARDIAL 1/4 CONNECTOR",
      "code_information": [
        {
          "code": "3082395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURG-STRIP 1/2X6       80-1451",
      "code_information": [
        {
          "code": "3082416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 296,
          "minimum": 62.16,
          "maximum": 216.7312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.2215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPRALOOP-BRUCKER/MESSROGHLI",
      "code_information": [
        {
          "code": "3082421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1727,
          "minimum": 362.67,
          "maximum": 1264.5094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1074.833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-NUKNITT 3X4      1943",
      "code_information": [
        {
          "code": "3082430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC-0       173024",
      "code_information": [
        {
          "code": "3082450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 536.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC 2-0 173023",
      "code_information": [
        {
          "code": "3082453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 536.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 698G",
      "code_information": [
        {
          "code": "3082542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-GORETEX CV-3      3N06A",
      "code_information": [
        {
          "code": "3082544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 423,
          "minimum": 88.83,
          "maximum": 309.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 263.2625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J947H",
      "code_information": [
        {
          "code": "3082558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONO PDSII        Z740D",
      "code_information": [
        {
          "code": "3082562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 305,
          "minimum": 64.05,
          "maximum": 223.321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 189.8228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ALIANCE        5060-05",
      "code_information": [
        {
          "code": "3082566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-FLOSEAL 10ML   1503352",
      "code_information": [
        {
          "code": "3082592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2592,
          "minimum": 544.32,
          "maximum": 1897.8624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1613.183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING NEMA   3730ANS",
      "code_information": [
        {
          "code": "3082996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2457.7391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ACCESSORY           502",
      "code_information": [
        {
          "code": "3083003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4011,
          "minimum": 842.31,
          "maximum": 2936.8542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2496.3261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BIOGLUE 5ML  BG3515-5US",
      "code_information": [
        {
          "code": "3083007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5122,
          "minimum": 1075.62,
          "maximum": 3750.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3187.7791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANS CATH 10\\\" PM040-A",
      "code_information": [
        {
          "code": "3083014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1368,
          "minimum": 287.28,
          "maximum": 1001.6496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 851.4022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-CYSTO 25X5/8  581610",
      "code_information": [
        {
          "code": "3083019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 50,
          "minimum": 10.5,
          "maximum": 36.61,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 31.1185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE VNUS        CFP",
      "code_information": [
        {
          "code": "3083021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION CATH  PM010-A",
      "code_information": [
        {
          "code": "3083022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 435,
          "minimum": 91.35,
          "maximum": 318.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 270.731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION 5\\\"    PM020-A",
      "code_information": [
        {
          "code": "3083023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 372.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-COLLECTION   003984-901",
      "code_information": [
        {
          "code": "3083083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.9635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-STERIDRAPE 8 7/8   1075",
      "code_information": [
        {
          "code": "3083104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URETERAL DIAL   240-100",
      "code_information": [
        {
          "code": "3083141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1497,
          "minimum": 314.37,
          "maximum": 1096.1034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 931.6879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-PROTACK DEVICE 5MM",
      "code_information": [
        {
          "code": "3083191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3464,
          "minimum": 727.44,
          "maximum": 2536.3408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2155.8897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB AR-13226",
      "code_information": [
        {
          "code": "3083200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 596,
          "minimum": 125.16,
          "maximum": 436.3912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 370.9325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-BONE SCREW 3.5X50  311.349",
      "code_information": [
        {
          "code": "3083203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.35 2883-02-043",
      "code_information": [
        {
          "code": "3083212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1503.6459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-IQ DISPOSABLE 72-1010",
      "code_information": [
        {
          "code": "3083214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 585.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-GLOW AND TELL     1100-20",
      "code_information": [
        {
          "code": "3083225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.9048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-          AR-7237-7T",
      "code_information": [
        {
          "code": "3083486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 520,
          "minimum": 109.2,
          "maximum": 380.744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 323.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS2",
      "code_information": [
        {
          "code": "3083597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-BIOGLUE FAN        BGST-12",
      "code_information": [
        {
          "code": "3083615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 150.6135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE ALL    UMx67x's",
      "code_information": [
        {
          "code": "3083622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1067,
          "minimum": 224.07,
          "maximum": 781.2574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 664.0688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 35CM     3908",
      "code_information": [
        {
          "code": "3083637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 290.0244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CURVED DISP I&A 8065751512",
      "code_information": [
        {
          "code": "3083715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE POLYMER I/A",
      "code_information": [
        {
          "code": "3083720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 222,
          "minimum": 46.62,
          "maximum": 162.5484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.1661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-TURBOSONICS     8065750853",
      "code_information": [
        {
          "code": "3083760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 464.9104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-VACURRETTE 5MM       21664",
      "code_information": [
        {
          "code": "3083764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.6357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-TUNNELING            1112",
      "code_information": [
        {
          "code": "3084399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 326.7442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-LUKI MUCOUS SPEC  8646-04",
      "code_information": [
        {
          "code": "3084800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 6",
      "code_information": [
        {
          "code": "3084821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 585.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA70",
      "code_information": [
        {
          "code": "3084824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.8152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA80",
      "code_information": [
        {
          "code": "3084827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1345,
          "minimum": 282.45,
          "maximum": 984.809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 837.0876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/METER ALL P4PxxSD",
      "code_information": [
        {
          "code": "3084870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.0266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CHG PREP        DYND70663",
      "code_information": [
        {
          "code": "3084874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.0133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BETADINE PREP   DYND70672",
      "code_information": [
        {
          "code": "3084876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1    4609764",
      "code_information": [
        {
          "code": "3084884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAPS-FINGER DISP PACK 9900s",
      "code_information": [
        {
          "code": "3084885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 118.2503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-LAP CB EXPLOR    G26908",
      "code_information": [
        {
          "code": "3084925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3560,
          "minimum": 747.6,
          "maximum": 2606.632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2215.6372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SOLU IRRISEPT .5% CHG",
      "code_information": [
        {
          "code": "3084928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 797,
          "minimum": 167.37,
          "maximum": 583.5634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 496.0289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INFLATION   03.804.413S",
      "code_information": [
        {
          "code": "3084946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP 26-23-0757",
      "code_information": [
        {
          "code": "3084992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFF74",
      "code_information": [
        {
          "code": "3085110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-100LP",
      "code_information": [
        {
          "code": "3085111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 906,
          "minimum": 190.26,
          "maximum": 663.3732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 563.8672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED     CTF73",
      "code_information": [
        {
          "code": "3085112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-100L",
      "code_information": [
        {
          "code": "3085113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 941,
          "minimum": 197.61,
          "maximum": 689.0002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 585.6502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREATED      CTF03",
      "code_information": [
        {
          "code": "3085117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-8MM KII OPTICAL   COQ19",
      "code_information": [
        {
          "code": "3085120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR47",
      "code_information": [
        {
          "code": "3085135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR85",
      "code_information": [
        {
          "code": "3085137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM KII OPTICAL  COR37",
      "code_information": [
        {
          "code": "3085140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 567,
          "minimum": 119.07,
          "maximum": 415.1574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 352.8838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM LONG         C0R39",
      "code_information": [
        {
          "code": "3085142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 567,
          "minimum": 119.07,
          "maximum": 415.1574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 352.8838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM KII FIOS      CFFxx",
      "code_information": [
        {
          "code": "3085145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM LONG BLADED CFB71",
      "code_information": [
        {
          "code": "3085160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-THORACOPOR 11.5  179303",
      "code_information": [
        {
          "code": "3085163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 882,
          "minimum": 185.22,
          "maximum": 645.8004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 548.9303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM THREADED     CTF33",
      "code_information": [
        {
          "code": "3085165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-SPLIT           82-4095",
      "code_information": [
        {
          "code": "3085170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2007,
          "minimum": 421.47,
          "maximum": 1469.5254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1249.0966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL BLADELESS     B8LT",
      "code_information": [
        {
          "code": "3085202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 482,
          "minimum": 101.22,
          "maximum": 352.9204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 299.9823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP LONG VS101505",
      "code_information": [
        {
          "code": "3085203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1367,
          "minimum": 287.07,
          "maximum": 1000.9174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 850.7798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 5MM           B5LT",
      "code_information": [
        {
          "code": "3085207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1543,
          "minimum": 324.03,
          "maximum": 1129.7846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 960.3169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12X100MM     H12LP",
      "code_information": [
        {
          "code": "3085208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 702,
          "minimum": 147.42,
          "maximum": 514.0044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 436.9037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN CUFF 7.0MM",
      "code_information": [
        {
          "code": "3085522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BIO PREP BONE PREP",
      "code_information": [
        {
          "code": "3085533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1349,
          "minimum": 283.29,
          "maximum": 987.7378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 839.5771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SPIKE INFILTRATION",
      "code_information": [
        {
          "code": "3085534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 8.0FR MEGA IAB",
      "code_information": [
        {
          "code": "3085537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1496,
          "minimum": 314.16,
          "maximum": 1095.3712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 931.0655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ARMSTRONG TEFLON DRAIN",
      "code_information": [
        {
          "code": "3085540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.7885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-TIBIAL 111651",
      "code_information": [
        {
          "code": "3085541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.1296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PROCEDURE TRACKING 107130",
      "code_information": [
        {
          "code": "3085542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE 111320",
      "code_information": [
        {
          "code": "3085543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 405,
          "minimum": 85.05,
          "maximum": 296.541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 252.0598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX IMPACTION",
      "code_information": [
        {
          "code": "3085544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 817,
          "minimum": 171.57,
          "maximum": 598.2074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 508.4763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144140",
      "code_information": [
        {
          "code": "3085545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 588.1396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX 116230",
      "code_information": [
        {
          "code": "3085546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 585.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON ULTRASIL",
      "code_information": [
        {
          "code": "3085560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-ENDO EXCEL 15MM   B15LT",
      "code_information": [
        {
          "code": "3085620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1548,
          "minimum": 325.08,
          "maximum": 1133.4456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 963.4288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR ARMSTRONG    10-56121",
      "code_information": [
        {
          "code": "3085635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.1872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR PAPARELLA 1.14MM",
      "code_information": [
        {
          "code": "3085636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.1872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACHEAL EMG  8229307",
      "code_information": [
        {
          "code": "3085638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1585,
          "minimum": 332.85,
          "maximum": 1160.537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 986.4565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH ALL SZS 822970x",
      "code_information": [
        {
          "code": "3085644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.1188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 20FR   0100-20",
      "code_information": [
        {
          "code": "3085648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-KAMVAC            5300-00",
      "code_information": [
        {
          "code": "3085723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 549.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MOSS GASTROSTOMY  5-17719",
      "code_information": [
        {
          "code": "3085779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1148.895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM PROX",
      "code_information": [
        {
          "code": "3085796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 420.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T MODIFIED        24-0072",
      "code_information": [
        {
          "code": "3085882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.9137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COLLECTION DISP BKT-506",
      "code_information": [
        {
          "code": "3086006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.9557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OXYFLEX        SA008000",
      "code_information": [
        {
          "code": "3086095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX INFLOW  AQL-110",
      "code_information": [
        {
          "code": "3086102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      80-9102",
      "code_information": [
        {
          "code": "3086103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 715,
          "minimum": 150.15,
          "maximum": 523.523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 444.9946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      5120-10",
      "code_information": [
        {
          "code": "3086105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 142.5227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AIRSEAL ASM-EVAC",
      "code_information": [
        {
          "code": "3086106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 963,
          "minimum": 202.23,
          "maximum": 705.1086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 599.3423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATOR STR  18-95522",
      "code_information": [
        {
          "code": "3086107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 542,
          "minimum": 113.82,
          "maximum": 396.8524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 337.3245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LASER VACUUM    VT10424",
      "code_information": [
        {
          "code": "3086109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LIPOSUCTION   DYND50112",
      "code_information": [
        {
          "code": "3086110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.1805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MAIN PUMP       AR-6410",
      "code_information": [
        {
          "code": "3086111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 476.113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/4\\\"X1/16\\\"X8'      3108",
      "code_information": [
        {
          "code": "3086139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 132,
          "minimum": 27.72,
          "maximum": 96.6504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.1528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OUTFLOW         AR-6430",
      "code_information": [
        {
          "code": "3086141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO      284508",
      "code_information": [
        {
          "code": "3086142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 450,
          "minimum": 94.5,
          "maximum": 329.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.0665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO IRRIG OUT",
      "code_information": [
        {
          "code": "3086144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.0233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-ASPIRATION AT-10003-6",
      "code_information": [
        {
          "code": "3086181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 122.6069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TISSEEL         0600065",
      "code_information": [
        {
          "code": "3086182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 629,
          "minimum": 132.09,
          "maximum": 460.5538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 391.4707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TRANSDUCER 48 61000",
      "code_information": [
        {
          "code": "3086185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARTHREX-TIB CANN      AR-1802D",
      "code_information": [
        {
          "code": "3086190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-& TIP-SMALL   9009-18",
      "code_information": [
        {
          "code": "3086203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 821,
          "minimum": 172.41,
          "maximum": 601.1362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 510.9658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER & TIP-LARGE   9009-16",
      "code_information": [
        {
          "code": "3086205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 724,
          "minimum": 152.04,
          "maximum": 530.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 450.5959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-STIMULATOR LEAD   402",
      "code_information": [
        {
          "code": "3086210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3245,
          "minimum": 681.45,
          "maximum": 2375.989,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2019.5906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE SUPPORT 79-82160",
      "code_information": [
        {
          "code": "3086407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 70x-xxxx ALL SIZES",
      "code_information": [
        {
          "code": "3086409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM VAS          XR30V",
      "code_information": [
        {
          "code": "3086955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 443,
          "minimum": 93.03,
          "maximum": 324.3646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 275.7099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH 2-0   170057",
      "code_information": [
        {
          "code": "3086965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 813,
          "minimum": 170.73,
          "maximum": 595.2786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 505.9868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VAC-SUPER TURBO     ASC4250-01",
      "code_information": [
        {
          "code": "3087110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 909.9049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP CVD ALL 21500s",
      "code_information": [
        {
          "code": "3087119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CURVED 7MM     21853",
      "code_information": [
        {
          "code": "3087130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 8MM CVD   20317",
      "code_information": [
        {
          "code": "3087132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VOICE-PROLARYN        8044M0K5",
      "code_information": [
        {
          "code": "3087140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3836,
          "minimum": 805.56,
          "maximum": 2808.7192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2387.4113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVULATOME-LEMAITRE   1009-00",
      "code_information": [
        {
          "code": "3087919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 13534,
          "minimum": 2842.14,
          "maximum": 9909.5948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8423.1556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8916-14",
      "code_information": [
        {
          "code": "3087939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 812,
          "minimum": 170.52,
          "maximum": 594.5464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 505.3644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 UNDYED    VLOCM1904",
      "code_information": [
        {
          "code": "3088955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J761D",
      "code_information": [
        {
          "code": "3088965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.2713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VIOLET    VLOCM0804",
      "code_information": [
        {
          "code": "3088967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 557,
          "minimum": 116.97,
          "maximum": 407.8354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.6601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0    MCP496G",
      "code_information": [
        {
          "code": "3088972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J441",
      "code_information": [
        {
          "code": "3088976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7.4684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS2     1666G",
      "code_information": [
        {
          "code": "3088979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J218H",
      "code_information": [
        {
          "code": "3088985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7.4684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y495G",
      "code_information": [
        {
          "code": "3088991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.5936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       D5526",
      "code_information": [
        {
          "code": "3088992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 799,
          "minimum": 167.79,
          "maximum": 585.0278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 497.2736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 6-0           Z432H",
      "code_information": [
        {
          "code": "3088993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0  ALL  833-000s",
      "code_information": [
        {
          "code": "3088998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.7232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J727D",
      "code_information": [
        {
          "code": "3089002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J905T",
      "code_information": [
        {
          "code": "3089005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J739D",
      "code_information": [
        {
          "code": "3089007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J906G",
      "code_information": [
        {
          "code": "3089013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.1108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J740D",
      "code_information": [
        {
          "code": "3089014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J775D",
      "code_information": [
        {
          "code": "3089024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.0687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J789D",
      "code_information": [
        {
          "code": "3089025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 134.4319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z881G",
      "code_information": [
        {
          "code": "3089026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8806H",
      "code_information": [
        {
          "code": "3089027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z990G",
      "code_information": [
        {
          "code": "3089030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J834G",
      "code_information": [
        {
          "code": "3089039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J833G",
      "code_information": [
        {
          "code": "3089042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8824G",
      "code_information": [
        {
          "code": "3089048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.7198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y493G",
      "code_information": [
        {
          "code": "3089059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y490G",
      "code_information": [
        {
          "code": "3089060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8521H",
      "code_information": [
        {
          "code": "3089064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8581H",
      "code_information": [
        {
          "code": "3089065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.7265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8557H",
      "code_information": [
        {
          "code": "3089066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8833H",
      "code_information": [
        {
          "code": "3089069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8623H",
      "code_information": [
        {
          "code": "3089072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8522H",
      "code_information": [
        {
          "code": "3089073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8534H",
      "code_information": [
        {
          "code": "3089074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J904T",
      "code_information": [
        {
          "code": "3089079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      PX82H",
      "code_information": [
        {
          "code": "3089097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8523H",
      "code_information": [
        {
          "code": "3089100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.0133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8706H",
      "code_information": [
        {
          "code": "3089103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8805H",
      "code_information": [
        {
          "code": "3089105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.7885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8709H",
      "code_information": [
        {
          "code": "3089106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 266,
          "minimum": 55.86,
          "maximum": 194.7652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 165.5504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8720H",
      "code_information": [
        {
          "code": "3089110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8556H",
      "code_information": [
        {
          "code": "3089113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.6357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8710H",
      "code_information": [
        {
          "code": "3089114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8304H",
      "code_information": [
        {
          "code": "3089117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 240,
          "minimum": 50.4,
          "maximum": 175.728,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 149.3688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8703H",
      "code_information": [
        {
          "code": "3089121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 251,
          "minimum": 52.71,
          "maximum": 183.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.2149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J213H",
      "code_information": [
        {
          "code": "3089123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO       AR-4068-xxx",
      "code_information": [
        {
          "code": "3089131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 909.9049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         G124H",
      "code_information": [
        {
          "code": "3089132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         U256H",
      "code_information": [
        {
          "code": "3089133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 2-0       G123H",
      "code_information": [
        {
          "code": "3089145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       1792G",
      "code_information": [
        {
          "code": "3089146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.1728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "3089147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 248,
          "minimum": 52.08,
          "maximum": 181.5856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 154.3478,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 0       L104G",
      "code_information": [
        {
          "code": "3089150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       G172H",
      "code_information": [
        {
          "code": "3089154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U203",
      "code_information": [
        {
          "code": "3089156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1637G",
      "code_information": [
        {
          "code": "3089157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0     1916G",
      "code_information": [
        {
          "code": "3089161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     1824H",
      "code_information": [
        {
          "code": "3089172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A304H",
      "code_information": [
        {
          "code": "3089177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 5-0          K890H",
      "code_information": [
        {
          "code": "3089195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           709H",
      "code_information": [
        {
          "code": "3089202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 118,
          "minimum": 24.78,
          "maximum": 86.3996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 73.4397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0  X524H",
      "code_information": [
        {
          "code": "3089204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5        B449T",
      "code_information": [
        {
          "code": "3089212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 4-0      X204H",
      "code_information": [
        {
          "code": "3089217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 3-0      X936H",
      "code_information": [
        {
          "code": "3089226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5-0      X727H",
      "code_information": [
        {
          "code": "3089227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.1805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        690G",
      "code_information": [
        {
          "code": "3089238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       1666H",
      "code_information": [
        {
          "code": "3089239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1663H",
      "code_information": [
        {
          "code": "3089244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z340H",
      "code_information": [
        {
          "code": "3089254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.2237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 0         L880G",
      "code_information": [
        {
          "code": "3089258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      SXP82",
      "code_information": [
        {
          "code": "3089266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 607,
          "minimum": 127.47,
          "maximum": 444.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 377.7786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND2-0       SXP86",
      "code_information": [
        {
          "code": "3089267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 666,
          "minimum": 139.86,
          "maximum": 487.6452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 414.4984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X927H",
      "code_information": [
        {
          "code": "3089281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z879G",
      "code_information": [
        {
          "code": "3089283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0 Z494G",
      "code_information": [
        {
          "code": "3089284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y497G",
      "code_information": [
        {
          "code": "3089286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.6357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0        687G",
      "code_information": [
        {
          "code": "3089287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X513H",
      "code_information": [
        {
          "code": "3089288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.2093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2 MX69G",
      "code_information": [
        {
          "code": "3089290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 134.4319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS O EZ10G",
      "code_information": [
        {
          "code": "3089291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 240.8572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          EJ10G",
      "code_information": [
        {
          "code": "3089292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 240.8572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       M8720",
      "code_information": [
        {
          "code": "3089293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 622,
          "minimum": 130.62,
          "maximum": 455.4284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 387.1141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       M8303",
      "code_information": [
        {
          "code": "3089294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 778,
          "minimum": 163.38,
          "maximum": 569.6516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 484.2039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       U202H",
      "code_information": [
        {
          "code": "3089307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U213H",
      "code_information": [
        {
          "code": "3089308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8843H",
      "code_information": [
        {
          "code": "3089314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J555G",
      "code_information": [
        {
          "code": "3089316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            C027D",
      "code_information": [
        {
          "code": "3089318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX45D",
      "code_information": [
        {
          "code": "3089320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 207,
          "minimum": 43.47,
          "maximum": 151.5654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.8306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 8-0         2815G",
      "code_information": [
        {
          "code": "3089323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X523H",
      "code_information": [
        {
          "code": "3089324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.2093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X977H",
      "code_information": [
        {
          "code": "3089325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 5-0     1915G",
      "code_information": [
        {
          "code": "3089326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.5936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0           Z774D",
      "code_information": [
        {
          "code": "3089328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.9557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 10-0      9003G",
      "code_information": [
        {
          "code": "3089335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 161.1938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        793G",
      "code_information": [
        {
          "code": "3089348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 699G",
      "code_information": [
        {
          "code": "3089354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON/MONO    ETH562H",
      "code_information": [
        {
          "code": "3089357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 CT1  J-945-H",
      "code_information": [
        {
          "code": "3089362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.2237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0        585H",
      "code_information": [
        {
          "code": "3089363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C0125",
      "code_information": [
        {
          "code": "3089364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMD2B413",
      "code_information": [
        {
          "code": "3089371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 200.4031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPD2B408",
      "code_information": [
        {
          "code": "3089372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 213.4729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       U204H",
      "code_information": [
        {
          "code": "3089379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J428H",
      "code_information": [
        {
          "code": "3089381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 46,
          "minimum": 9.66,
          "maximum": 33.6812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 28.629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6/0 P-1    J489G",
      "code_information": [
        {
          "code": "3089382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 7-0        J488G",
      "code_information": [
        {
          "code": "3089384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPP1A400",
      "code_information": [
        {
          "code": "3089386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 370,
          "minimum": 77.7,
          "maximum": 270.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.2769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2.0 ALL PX83Hs",
      "code_information": [
        {
          "code": "3089390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1654G",
      "code_information": [
        {
          "code": "3089394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NUROLON 4-0       C584D",
      "code_information": [
        {
          "code": "3089396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 236,
          "minimum": 49.56,
          "maximum": 172.7992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 146.8793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPD2B413",
      "code_information": [
        {
          "code": "3089403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 391,
          "minimum": 82.11,
          "maximum": 286.2902,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 243.3467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z493G",
      "code_information": [
        {
          "code": "3089407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN 4-0 1644G",
      "code_information": [
        {
          "code": "3089408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE RS23",
      "code_information": [
        {
          "code": "3089410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC PBT xxMM",
      "code_information": [
        {
          "code": "3089416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 423.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1B406",
      "code_information": [
        {
          "code": "3089420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 380,
          "minimum": 79.8,
          "maximum": 278.236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 236.5006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MONOPTY 16GX20CM",
      "code_information": [
        {
          "code": "3089701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE EICA8875-01",
      "code_information": [
        {
          "code": "3090040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2017,
          "minimum": 423.57,
          "maximum": 1476.8474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1255.3203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-TURBINATE RED EICA4845-01",
      "code_information": [
        {
          "code": "3090049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2053,
          "minimum": 431.13,
          "maximum": 1503.2066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1277.7256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,TOPAZ MICRO ACH4041-0",
      "code_information": [
        {
          "code": "3090061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1671.0634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .045      WS-1106ST",
      "code_information": [
        {
          "code": "3090191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER #2          AR-7200",
      "code_information": [
        {
          "code": "3091195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.6756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER 2-0         AR-7220",
      "code_information": [
        {
          "code": "3091196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.6756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5         310.243",
      "code_information": [
        {
          "code": "3091211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 530.2592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.8MM        292.68",
      "code_information": [
        {
          "code": "3091218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 623,
          "minimum": 130.83,
          "maximum": 456.1606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 387.7365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6MM AGK16150",
      "code_information": [
        {
          "code": "3091237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 290.0244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-2.5MM DRILL XFO082501",
      "code_information": [
        {
          "code": "3091238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE          1806-0080S",
      "code_information": [
        {
          "code": "3091250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1197,
          "minimum": 251.37,
          "maximum": 876.4434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 744.9769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3091317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .054          WS-1406ST",
      "code_information": [
        {
          "code": "3091319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K              0152-0218S",
      "code_information": [
        {
          "code": "3091346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 881,
          "minimum": 185.01,
          "maximum": 645.0682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 548.308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 040-365",
      "code_information": [
        {
          "code": "3091419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1510,
          "minimum": 317.1,
          "maximum": 1105.622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 939.7787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 046-072",
      "code_information": [
        {
          "code": "3091422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 357,
          "minimum": 74.97,
          "maximum": 261.3954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.1861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY    047-032",
      "code_information": [
        {
          "code": "3091425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 295,
          "minimum": 61.95,
          "maximum": 215.999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 183.5991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE TIP      03.211.410",
      "code_information": [
        {
          "code": "3091436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 616,
          "minimum": 129.36,
          "maximum": 451.0352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 383.3799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 5.0 310.63",
      "code_information": [
        {
          "code": "3091500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3340,
          "minimum": 701.4,
          "maximum": 2445.548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2078.7158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 21665",
      "code_information": [
        {
          "code": "3091501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION SEID",
      "code_information": [
        {
          "code": "3091510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 890,
          "minimum": 186.9,
          "maximum": 651.658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 553.9093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND M 2.5MM 03.000.007S",
      "code_information": [
        {
          "code": "3091511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 492.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/2X3/32 /10 3610",
      "code_information": [
        {
          "code": "3091513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 118.2503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLUE-GUN CMS REVOLUTION",
      "code_information": [
        {
          "code": "3091516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1029,
          "minimum": 216.09,
          "maximum": 753.4338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 640.4187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT 5MM EB210",
      "code_information": [
        {
          "code": "3091517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1420.2483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT FINE EB230",
      "code_information": [
        {
          "code": "3091518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2953,
          "minimum": 620.13,
          "maximum": 2162.1866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1837.8586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE CANNU FLEX .042X12",
      "code_information": [
        {
          "code": "3091560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 351.0167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TEMPORARY CARDIA  024-100",
      "code_information": [
        {
          "code": "3091561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.6767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8MM FIBULA ROD 80-0642",
      "code_information": [
        {
          "code": "3091572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.8152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-FACIAL DENTAL 714-6IN-GEL",
      "code_information": [
        {
          "code": "3093187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 249,
          "minimum": 52.29,
          "maximum": 182.3178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 154.9701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ACCESSORY       3550-02",
      "code_information": [
        {
          "code": "3093195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 585.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOBUTTON-CL ULTRA PAC 1.2",
      "code_information": [
        {
          "code": "3094000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2461,
          "minimum": 516.81,
          "maximum": 1801.9442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1531.6526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACCESSORY-TIP COVER     400180",
      "code_information": [
        {
          "code": "3100010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SNAPFIT 15 DEG    400152",
      "code_information": [
        {
          "code": "3102750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCL0316",
      "code_information": [
        {
          "code": "3115410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCM1545",
      "code_information": [
        {
          "code": "3115420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA ARM        420279",
      "code_information": [
        {
          "code": "3115515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA HEAD       420273",
      "code_information": [
        {
          "code": "3115525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM    420015",
      "code_information": [
        {
          "code": "3115580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM XI 470015",
      "code_information": [
        {
          "code": "3115585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 652,
          "minimum": 136.92,
          "maximum": 477.3944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.7852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT COLUMN 470341",
      "code_information": [
        {
          "code": "3115590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM LONG XI   470358",
      "code_information": [
        {
          "code": "3155025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 234.0111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM XI        470357",
      "code_information": [
        {
          "code": "3155030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 234.0111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 5MM        400161",
      "code_information": [
        {
          "code": "3170005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 8.5-13MM   420206",
      "code_information": [
        {
          "code": "3170007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA            400077",
      "code_information": [
        {
          "code": "3170010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA ENDOWRIST XI",
      "code_information": [
        {
          "code": "3170020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-8MM XI 570361",
      "code_information": [
        {
          "code": "3170050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL s.I.e.    410322",
      "code_information": [
        {
          "code": "3170060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2089.2961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL XI        480322",
      "code_information": [
        {
          "code": "3170070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2089.2961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUB. & FILTER 20400162S/10",
      "code_information": [
        {
          "code": "3171250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 190.4452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-ENDOWRIST STAPLER 45",
      "code_information": [
        {
          "code": "3171320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909506",
      "code_information": [
        {
          "code": "3171350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11962,
          "minimum": 2512.02,
          "maximum": 8758.5764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7444.7899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 12M OMS-T12BT",
      "code_information": [
        {
          "code": "3175750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1756,
          "minimum": 368.76,
          "maximum": 1285.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1092.8817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-SINGLE SITE 8.5    428065",
      "code_information": [
        {
          "code": "3185345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1488,
          "minimum": 312.48,
          "maximum": 1089.5136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 926.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEXIBLE         3100A",
      "code_information": [
        {
          "code": "3240013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1449,
          "minimum": 304.29,
          "maximum": 1060.9578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.8141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GENERATOR INFANT LP FLOW",
      "code_information": [
        {
          "code": "3240072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 596,
          "minimum": 125.16,
          "maximum": 436.3912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 370.9325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INFANT O2 DELIVERY   RT329",
      "code_information": [
        {
          "code": "3240073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 476,
          "minimum": 99.96,
          "maximum": 348.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.2481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RESUS S/USE       900RD010",
      "code_information": [
        {
          "code": "3240075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG HYDROGEL",
      "code_information": [
        {
          "code": "3240083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODES-EEG LOW IMPEDENCE",
      "code_information": [
        {
          "code": "3240085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTERFACE-TRACHEOSTOMY HI FLOW",
      "code_information": [
        {
          "code": "3240105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 203.515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BELLOWS & WATER TRAP 3100A",
      "code_information": [
        {
          "code": "3240167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CONNECTING TUBING.   3100",
      "code_information": [
        {
          "code": "3240170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 6 FR    196",
      "code_information": [
        {
          "code": "3249995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 116.3832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 8 FR    198",
      "code_information": [
        {
          "code": "3249997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 116.3832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE MAC 5FR    1925",
      "code_information": [
        {
          "code": "3249998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 118.8727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE 14FR 12\\\" 220135",
      "code_information": [
        {
          "code": "3250000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.9291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT UNCUFFED",
      "code_information": [
        {
          "code": "3281990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3282370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XS      006950",
      "code_information": [
        {
          "code": "3283013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.5161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP THERAPY  \\\"ACAPELLA\\\"",
      "code_information": [
        {
          "code": "3283015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION  LG     006965",
      "code_information": [
        {
          "code": "3283017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XLG     006970",
      "code_information": [
        {
          "code": "3283018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUVETTE-CO2 DISP ADULT MP01062",
      "code_information": [
        {
          "code": "3284354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.2293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER 5MM",
      "code_information": [
        {
          "code": "3290045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL MED HIGH FLOW",
      "code_information": [
        {
          "code": "3290046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.9137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL SM HIGH FLOW",
      "code_information": [
        {
          "code": "3290047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL LG HIGH FLOW",
      "code_information": [
        {
          "code": "3290048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP           23-0757",
      "code_information": [
        {
          "code": "3290060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 189.2005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT L599-130",
      "code_information": [
        {
          "code": "3290061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.0687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT W/MR290 SINGLE",
      "code_information": [
        {
          "code": "3290062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 370,
          "minimum": 77.7,
          "maximum": 270.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.2769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BREATHING NEONATAL",
      "code_information": [
        {
          "code": "3290074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-INFANT DUAL FLOW RT26",
      "code_information": [
        {
          "code": "3290077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 275.0875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOWMETER-PEAK          002068",
      "code_information": [
        {
          "code": "3290080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.1108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-CPAP NASAL NSC-001",
      "code_information": [
        {
          "code": "3290082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOW-CONT CYSTO GREENLYT",
      "code_information": [
        {
          "code": "3290084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP MED",
      "code_information": [
        {
          "code": "3290127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.5161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP SMALL",
      "code_information": [
        {
          "code": "3290128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.5161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOSE-AIR MODEL 205 DISP",
      "code_information": [
        {
          "code": "3290145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.5725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED SM NIV",
      "code_information": [
        {
          "code": "3290170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED MED NIV",
      "code_information": [
        {
          "code": "3290171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED LG NIV",
      "code_information": [
        {
          "code": "3290172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 42MM    RD804-10",
      "code_information": [
        {
          "code": "3290178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.4817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP AIRLIFE W/FILTER",
      "code_information": [
        {
          "code": "3290184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL XS INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 309,
          "minimum": 64.89,
          "maximum": 226.2498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 192.3123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL LG INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL MED INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 177.3755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 308,
          "minimum": 64.68,
          "maximum": 225.5176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 60MM    RD806-10",
      "code_information": [
        {
          "code": "3290194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK,OXY ADULT OM-1125-8",
      "code_information": [
        {
          "code": "3290214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED SMALL NIV",
      "code_information": [
        {
          "code": "3290215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.7952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.9557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED LARGE NIV",
      "code_information": [
        {
          "code": "3290217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.7952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 143.7675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED LG NIV",
      "code_information": [
        {
          "code": "3290219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.7044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP ALOHA ALO100",
      "code_information": [
        {
          "code": "3290220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 704,
          "minimum": 147.84,
          "maximum": 515.4688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 438.1485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-MISTY FINITY  002534",
      "code_information": [
        {
          "code": "3290245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 119,
          "minimum": 24.99,
          "maximum": 87.1318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOPPER-DECANNULATION SZ4",
      "code_information": [
        {
          "code": "3290354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 760,
          "minimum": 159.6,
          "maximum": 556.472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 473.0012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DIRECTIONAL BALLARD  22059",
      "code_information": [
        {
          "code": "3290385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.3976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 5MM PROX",
      "code_information": [
        {
          "code": "3290400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 699,
          "minimum": 146.79,
          "maximum": 511.8078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 435.0366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY SLT UNCUFF 5MM",
      "code_information": [
        {
          "code": "3290401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 679,
          "minimum": 142.59,
          "maximum": 497.1638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 422.5892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEST-SPU ALL SZS  WRAP-SLOTTED",
      "code_information": [
        {
          "code": "3290504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 819,
          "minimum": 171.99,
          "maximum": 599.6718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 509.721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING WHITE    PMV005",
      "code_information": [
        {
          "code": "3290506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 876,
          "minimum": 183.96,
          "maximum": 641.4072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 545.1961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING PURPLE  PMV2001",
      "code_information": [
        {
          "code": "3290508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 875,
          "minimum": 183.75,
          "maximum": 640.675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 544.5738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP LPEEP",
      "code_information": [
        {
          "code": "3290509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP ADJ          2K8082",
      "code_information": [
        {
          "code": "3290515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-THERAPRESSURE     262895",
      "code_information": [
        {
          "code": "3300010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 51,
          "minimum": 10.71,
          "maximum": 37.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 31.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOFT GOODS FOR CPM UNIT",
      "code_information": [
        {
          "code": "3302945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 204.7597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA VARICEX S",
      "code_information": [
        {
          "code": "3310024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.6567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-ENDURA KIT         775410",
      "code_information": [
        {
          "code": "3310985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.9779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BGE   A840235",
      "code_information": [
        {
          "code": "3310986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BLACK  554617",
      "code_information": [
        {
          "code": "3310987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.7121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX RED   A840241",
      "code_information": [
        {
          "code": "3310989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 6CMX5CM",
      "code_information": [
        {
          "code": "3310991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 8CMX5CM",
      "code_information": [
        {
          "code": "3310992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 10CMX5M",
      "code_information": [
        {
          "code": "3310993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDL K 12CMX5M",
      "code_information": [
        {
          "code": "3311000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.0199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL 15CMX.4CMX2.5M",
      "code_information": [
        {
          "code": "3311010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.0266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ12 12CM",
      "code_information": [
        {
          "code": "3311075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 290,
          "minimum": 60.9,
          "maximum": 212.338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 180.4873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ7 7CM",
      "code_information": [
        {
          "code": "3311076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL SOFT",
      "code_information": [
        {
          "code": "3311078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING C",
      "code_information": [
        {
          "code": "3311085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AID-\\\"CLEAN EASY\\\" GRIP REACH",
      "code_information": [
        {
          "code": "3311086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.2636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING D",
      "code_information": [
        {
          "code": "3311094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.6767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3311107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-LG HDL      C6298-01-25",
      "code_information": [
        {
          "code": "3311117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 53,
          "minimum": 11.13,
          "maximum": 38.8066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.9856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3311123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 6CMX5M",
      "code_information": [
        {
          "code": "3311138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 8CMX5M RL",
      "code_information": [
        {
          "code": "3311139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.3976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-IONTOPHOR IOGEL 2971",
      "code_information": [
        {
          "code": "3311144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYBRESIS PATCH",
      "code_information": [
        {
          "code": "3311150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALU 1.5X3.5 PK 2393",
      "code_information": [
        {
          "code": "3311153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ALUM LTX FREE ALL",
      "code_information": [
        {
          "code": "3311156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.4673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXERCISER-POWER GRIP HAND",
      "code_information": [
        {
          "code": "3311157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.7608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-COMFY HAND/THUMB",
      "code_information": [
        {
          "code": "3311158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 723,
          "minimum": 151.83,
          "maximum": 529.3806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 449.9735,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3311161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUTRODE RND 1.25\\\"",
      "code_information": [
        {
          "code": "3311163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT OVAL PK 2\\\"X4\\\"",
      "code_information": [
        {
          "code": "3311164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-WEIGHTED EZ GRIP 920675",
      "code_information": [
        {
          "code": "3311165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELECTRODE ADULT       9050",
      "code_information": [
        {
          "code": "3311167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3311174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.7044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT SQ PK  1.5X3.5",
      "code_information": [
        {
          "code": "3311178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.0764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT M&LGE",
      "code_information": [
        {
          "code": "3311191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARD-FOOD INVISIBLE      1115",
      "code_information": [
        {
          "code": "3311192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-TRACTION EXER ALL C5032s",
      "code_information": [
        {
          "code": "3311193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.7121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT S&XS",
      "code_information": [
        {
          "code": "3311194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LAVAGE    0210112000",
      "code_information": [
        {
          "code": "3311197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 504,
          "minimum": 105.84,
          "maximum": 369.0288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 313.6745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPM SOFTGOOD FOR HOME UNIT",
      "code_information": [
        {
          "code": "3311235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 204.7597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3311250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HIP/KNEE W/26 REACHER",
      "code_information": [
        {
          "code": "3311251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH UPPER EXTREMITY",
      "code_information": [
        {
          "code": "3311255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.7608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-ELASTO-GEL CAST/SPL  A8273",
      "code_information": [
        {
          "code": "3311340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.3632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3311347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3311357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-D WRIST BRACE ALL SIZES",
      "code_information": [
        {
          "code": "3311363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.3345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADDING-FOAM \\\"KOMPREX\\\" SHEET",
      "code_information": [
        {
          "code": "3311369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPOON-WEIGHTED EZ GRIP 920688",
      "code_information": [
        {
          "code": "3311406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-LONG-32\\\"       A665009",
      "code_information": [
        {
          "code": "3311472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-ALUMINUM 32\\\"      4107",
      "code_information": [
        {
          "code": "3311475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.3632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-STANDARD 26\\\"    A80-42",
      "code_information": [
        {
          "code": "3311479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-SAMMONS PRESTON   4109",
      "code_information": [
        {
          "code": "3311480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINTING-EZEFORM 1/8”X18”X24”",
      "code_information": [
        {
          "code": "3311600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 475,
          "minimum": 99.75,
          "maximum": 347.795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 295.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELBOW NEOPRENE XL",
      "code_information": [
        {
          "code": "3311602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.3134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-JOINT JACK MED   A52542",
      "code_information": [
        {
          "code": "3311613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 6\\\"-7\\\"",
      "code_information": [
        {
          "code": "3311625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 213.4729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 3-14",
      "code_information": [
        {
          "code": "3311701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT S/M A812731",
      "code_information": [
        {
          "code": "3311702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND COMFY LG ADULT",
      "code_information": [
        {
          "code": "3311703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 444,
          "minimum": 93.24,
          "maximum": 325.0968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.3323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT/LARGE DYNAPRO",
      "code_information": [
        {
          "code": "3311704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 464.9104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-STABILIZER WALKER ROLYAN",
      "code_information": [
        {
          "code": "3311708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 463,
          "minimum": 97.23,
          "maximum": 339.0086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 288.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WALKER HIGH OVATION LRG",
      "code_information": [
        {
          "code": "3311709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 341.6811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-LMB FINGER HUGGER",
      "code_information": [
        {
          "code": "3312530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 152.4806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EZEFORM-ANTI MICROBIAL 564393",
      "code_information": [
        {
          "code": "3315521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 572,
          "minimum": 120.12,
          "maximum": 418.8184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 355.9956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3397811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 217.2071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PALM SHIELD RIGHT",
      "code_information": [
        {
          "code": "3397815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND RIGHT/MED A31228",
      "code_information": [
        {
          "code": "3397817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT MED A31227",
      "code_information": [
        {
          "code": "3397818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SYRINGE SSS-STP-SP",
      "code_information": [
        {
          "code": "3500008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-SKIN DERMABOND  DNX12",
      "code_information": [
        {
          "code": "3500034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SOFTGOODS CPM        20533",
      "code_information": [
        {
          "code": "3500038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "3500087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.6567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LMA DISP ALL SZ  1250xx",
      "code_information": [
        {
          "code": "3500245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 34FR  123034",
      "code_information": [
        {
          "code": "3500275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 28F   123028",
      "code_information": [
        {
          "code": "3500280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 26FR  123026",
      "code_information": [
        {
          "code": "3500283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 30FR  123030",
      "code_information": [
        {
          "code": "3500285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 32FR  123032",
      "code_information": [
        {
          "code": "3500288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACMENT KNEE COLD L/XL",
      "code_information": [
        {
          "code": "3500410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED & 60MM AIRWAY",
      "code_information": [
        {
          "code": "3500786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT & 90MM AIRWY",
      "code_information": [
        {
          "code": "3500788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.0687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASPIRATOR-MECONIUM HCI   N0101",
      "code_information": [
        {
          "code": "3500789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-INFANT  5442160xx",
      "code_information": [
        {
          "code": "3500792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-COLLECTION 4X8 BX     9778",
      "code_information": [
        {
          "code": "3500815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    C0135T",
      "code_information": [
        {
          "code": "3501012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0        697H",
      "code_information": [
        {
          "code": "3501065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 FS-3  1665G",
      "code_information": [
        {
          "code": "3501070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXTERNAL CSF DRAIN INS8700",
      "code_information": [
        {
          "code": "3501130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 448,
          "minimum": 94.08,
          "maximum": 328.0256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 278.8218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC VERALNK ULTLNK500",
      "code_information": [
        {
          "code": "3501755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 666,
          "minimum": 139.86,
          "maximum": 487.6452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 414.4984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18FR5CC 0119L18",
      "code_information": [
        {
          "code": "3501790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC       6261",
      "code_information": [
        {
          "code": "3502002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EFFLUENT 5L PRISMAFLEX",
      "code_information": [
        {
          "code": "3502007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.0687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 20F30C  0167L20",
      "code_information": [
        {
          "code": "3502010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL   TCS1000",
      "code_information": [
        {
          "code": "3502048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 369,
          "minimum": 77.49,
          "maximum": 270.1818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.6545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 400     7000LL",
      "code_information": [
        {
          "code": "3502063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST MED RIGHT 5001-0",
      "code_information": [
        {
          "code": "3502580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.4463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LARGE RT  5001-04",
      "code_information": [
        {
          "code": "3502590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.4463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-LIFEBAND FOR AUTOPULSE",
      "code_information": [
        {
          "code": "3502593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1266,
          "minimum": 265.86,
          "maximum": 926.9652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 787.9204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST X-LG LT 5001-10",
      "code_information": [
        {
          "code": "3502600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-FLEXMASTER 6\\\" 79-98718",
      "code_information": [
        {
          "code": "3502681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.9358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF C",
      "code_information": [
        {
          "code": "3502706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 547,
          "minimum": 114.87,
          "maximum": 400.5134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 340.4364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF D",
      "code_information": [
        {
          "code": "3502707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 475,
          "minimum": 99.75,
          "maximum": 347.795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 295.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-BUNNY W/FRAME & LINER",
      "code_information": [
        {
          "code": "3502709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 351,
          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 218.4519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-LEG FULL SM 9128-01",
      "code_information": [
        {
          "code": "3502720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 345,
          "minimum": 72.45,
          "maximum": 252.609,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.7176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3502751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.4463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMIN 46-62 13992000",
      "code_information": [
        {
          "code": "3503080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-HOOD ALL  0408-8xx-000",
      "code_information": [
        {
          "code": "3503348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 679,
          "minimum": 142.59,
          "maximum": 497.1638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 422.5892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ENV INFANT   8004-01",
      "code_information": [
        {
          "code": "3503370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT ARM",
      "code_information": [
        {
          "code": "3504148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT BOOT",
      "code_information": [
        {
          "code": "3504149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT FULL LENGTH",
      "code_information": [
        {
          "code": "3504150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.9291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED ARM",
      "code_information": [
        {
          "code": "3504151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED BOOT",
      "code_information": [
        {
          "code": "3504152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 12\\\" 13960000*",
      "code_information": [
        {
          "code": "3504230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER EYE        607120",
      "code_information": [
        {
          "code": "3504353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MAC 3&4",
      "code_information": [
        {
          "code": "3504355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.2924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MIL 2&3",
      "code_information": [
        {
          "code": "3504357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.2924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "3504552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1.5\\\" CT\\\"",
      "code_information": [
        {
          "code": "3504553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM      100 1974",
      "code_information": [
        {
          "code": "3504663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 326,
          "minimum": 68.46,
          "maximum": 238.6972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.8926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM     12-7 1972",
      "code_information": [
        {
          "code": "3504665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CHANNELED         KVL03C",
      "code_information": [
        {
          "code": "3504905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST EZWALK XL 2001-05",
      "code_information": [
        {
          "code": "3505035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.1805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST STAT ALL 2001-00s",
      "code_information": [
        {
          "code": "3505545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.1805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA TENDERWRAP 4\\\"X10YDS",
      "code_information": [
        {
          "code": "3505570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WAFFLE  ALL SIZES    FW's",
      "code_information": [
        {
          "code": "3505575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2515H****",
      "code_information": [
        {
          "code": "3505815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.7265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICAL MED",
      "code_information": [
        {
          "code": "3505906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.5725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE HEAVY LARGE",
      "code_information": [
        {
          "code": "3505907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.1041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE CHILD   3004-12",
      "code_information": [
        {
          "code": "3505955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.5725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION ATEC",
      "code_information": [
        {
          "code": "3506118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.0133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3506181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-7FR \\\"SLIC\\\"       SC-14701",
      "code_information": [
        {
          "code": "3506470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.7542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CURITY ULTRAMER 6FR  6006",
      "code_information": [
        {
          "code": "3506758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 22G   383591",
      "code_information": [
        {
          "code": "3507108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 24G   383590",
      "code_information": [
        {
          "code": "3507111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW ARTERIAL VENOUS",
      "code_information": [
        {
          "code": "3507185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.0964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3W 16F 5CC  0119L16",
      "code_information": [
        {
          "code": "3507187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 30CC ALL 123600As",
      "code_information": [
        {
          "code": "3507190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 12 5 165812",
      "code_information": [
        {
          "code": "3507192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 14 5 165814",
      "code_information": [
        {
          "code": "3507193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 16 5 165816",
      "code_information": [
        {
          "code": "3507194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 18 5 165818",
      "code_information": [
        {
          "code": "3507195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 20 5 165820",
      "code_information": [
        {
          "code": "3507196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 22 5 165822",
      "code_information": [
        {
          "code": "3507197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 24 5 165824",
      "code_information": [
        {
          "code": "3507198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18F 0125RL18",
      "code_information": [
        {
          "code": "3507371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 260,
          "minimum": 54.6,
          "maximum": 190.372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 161.8162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 20F 30C W/V  0125RL20",
      "code_information": [
        {
          "code": "3507373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 22FR/30CC",
      "code_information": [
        {
          "code": "3507381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.1805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 24F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 163.6833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 26F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 20FR 30CC      266720",
      "code_information": [
        {
          "code": "3507665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.0764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 24FR 30CC      266724",
      "code_information": [
        {
          "code": "3507670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3CC   8887603101",
      "code_information": [
        {
          "code": "3507688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W  8F  3CC   8887603085",
      "code_information": [
        {
          "code": "3507852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-OXIMETRY 5 LUMEN  5032805",
      "code_information": [
        {
          "code": "3508302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1222,
          "minimum": 256.62,
          "maximum": 894.7484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 760.5361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SOAKER 1\\\"           PM030",
      "code_information": [
        {
          "code": "3508888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 719,
          "minimum": 150.99,
          "maximum": 526.4518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 447.484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-20X1.5 RADIO ARTE RA04220",
      "code_information": [
        {
          "code": "3509147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.0266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 16FR  010116",
      "code_information": [
        {
          "code": "3509269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 14FR  010114",
      "code_information": [
        {
          "code": "3509270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN STRAIGHT 18FR",
      "code_information": [
        {
          "code": "3509305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-CHEST DRAIN 9.6FR",
      "code_information": [
        {
          "code": "3509905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 161.1938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP ADJ     AA11",
      "code_information": [
        {
          "code": "3509911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.7331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-LOW TEMP ADJ      AA02",
      "code_information": [
        {
          "code": "3509912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3510001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.7187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COA 04273",
      "code_information": [
        {
          "code": "3510002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3510099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEX 72\\\"   DF47x-6121Z",
      "code_information": [
        {
          "code": "3510143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENTILATOR COAX",
      "code_information": [
        {
          "code": "3510148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLEANSER-BODY FOAMING REMEDY",
      "code_information": [
        {
          "code": "3510305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCLIP-MEDIUM         523800",
      "code_information": [
        {
          "code": "3510401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.8871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL SMALL 710-SMAL",
      "code_information": [
        {
          "code": "3510714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL MEDIUM 710-MED",
      "code_information": [
        {
          "code": "3510715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.67,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK PEDI-SELE",
      "code_information": [
        {
          "code": "3510817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL ALL SZ A11500x",
      "code_information": [
        {
          "code": "3510830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3511220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.3632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y PRISMAFLEX",
      "code_information": [
        {
          "code": "3511240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISP F/NEOBLUE COZY",
      "code_information": [
        {
          "code": "3511668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FOOT PNEU LRG PR  VP520L",
      "code_information": [
        {
          "code": "3511672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.2647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FT PNEU REGULAR PR VP520",
      "code_information": [
        {
          "code": "3511673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE LTX-FREE   610-002",
      "code_information": [
        {
          "code": "3511677",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT MED LF/ALUM  7703",
      "code_information": [
        {
          "code": "3511781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-YOUTH LF/ALUM      7702",
      "code_information": [
        {
          "code": "3511795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3511958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 189.2005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB TALL",
      "code_information": [
        {
          "code": "3511962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 189.2005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-WAFFLE 16x16x2  200WCI",
      "code_information": [
        {
          "code": "3512318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.6977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FOAM W/COVER    154264",
      "code_information": [
        {
          "code": "3512506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 211,
          "minimum": 44.31,
          "maximum": 154.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 131.3201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 16-18FR",
      "code_information": [
        {
          "code": "3512575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.9779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.1CM 9231",
      "code_information": [
        {
          "code": "3512760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.8871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.2CM 9232",
      "code_information": [
        {
          "code": "3512761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 81.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ANCHOR PICC LNE PIC0220",
      "code_information": [
        {
          "code": "3512770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 PED PEDI CAP",
      "code_information": [
        {
          "code": "3512773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.67,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RESQPOD 029-12-0242-000",
      "code_information": [
        {
          "code": "3512775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 809.081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FEMOSTOP         11165",
      "code_information": [
        {
          "code": "3512782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH STABILIZ    DIO120",
      "code_information": [
        {
          "code": "3512792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH SECURMENT VPPDFP",
      "code_information": [
        {
          "code": "3512794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL  SMALL  S-22MM",
      "code_information": [
        {
          "code": "3513121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.7331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL MEDIUM  M-29MM",
      "code_information": [
        {
          "code": "3513123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.9358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-ACCU ANTI-REFLUX INS8401",
      "code_information": [
        {
          "code": "3513202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1657,
          "minimum": 347.97,
          "maximum": 1213.2554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1031.2671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST VALVE PNEUMOSTAT",
      "code_information": [
        {
          "code": "3513225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT PRATT        SU130s",
      "code_information": [
        {
          "code": "3513231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE W/ISO BAG    1003",
      "code_information": [
        {
          "code": "3513475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.7198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM SM SIMP CS",
      "code_information": [
        {
          "code": "3514025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 414,
          "minimum": 86.94,
          "maximum": 303.1308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.6612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM BRIDGE",
      "code_information": [
        {
          "code": "3514230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 640,
          "minimum": 134.4,
          "maximum": 468.608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 398.3168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-PREVENA 45ML",
      "code_information": [
        {
          "code": "3514251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 367,
          "minimum": 77.07,
          "maximum": 268.7174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 228.4098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC 500ML WITH GEL",
      "code_information": [
        {
          "code": "3514255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO MED",
      "code_information": [
        {
          "code": "3514259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1213,
          "minimum": 254.73,
          "maximum": 888.1586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 754.9348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO SM",
      "code_information": [
        {
          "code": "3514261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYME 4X4 5044",
      "code_information": [
        {
          "code": "3514264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.2304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM     10X15CM",
      "code_information": [
        {
          "code": "3514272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 118.8727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDITRACE 31319281**",
      "code_information": [
        {
          "code": "3514650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5FR   006173P",
      "code_information": [
        {
          "code": "3514812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1649,
          "minimum": 346.29,
          "maximum": 1207.3978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1026.2881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-REDIPAK",
      "code_information": [
        {
          "code": "3514819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.6977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLOOD        SQ40S",
      "code_information": [
        {
          "code": "3516138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTERLINE-INTUBATED SET 185",
      "code_information": [
        {
          "code": "3516160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-MR 9GX14CM 20MM",
      "code_information": [
        {
          "code": "3518855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2344,
          "minimum": 492.24,
          "maximum": 1716.2768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1458.8353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX16CM",
      "code_information": [
        {
          "code": "3518857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 356.618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX1xCM",
      "code_information": [
        {
          "code": "3518865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 356.618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX1xCM",
      "code_information": [
        {
          "code": "3518868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX10CM",
      "code_information": [
        {
          "code": "3518870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 578,
          "minimum": 121.38,
          "maximum": 423.2116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 359.7299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-LARYNGOSCOPE DISP",
      "code_information": [
        {
          "code": "3518940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.4817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1962",
      "code_information": [
        {
          "code": "3519300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1034,
          "minimum": 217.14,
          "maximum": 757.0948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 643.5306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS LF ADLT",
      "code_information": [
        {
          "code": "3519395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUGGER-HEART STERNUM ALL 1000s",
      "code_information": [
        {
          "code": "3519770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.7399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 12F 36\\\"",
      "code_information": [
        {
          "code": "3520193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.9081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 20F 5CC",
      "code_information": [
        {
          "code": "3520196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 95.845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 22FR 20CC",
      "code_information": [
        {
          "code": "3520199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 145.0122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INHALER-DIAMOND SPACR 107-9830",
      "code_information": [
        {
          "code": "3520701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-INTUBATION ALL Gs",
      "code_information": [
        {
          "code": "3521014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1015,
          "minimum": 213.15,
          "maximum": 743.183,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 631.7056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ALGO HEARING TEST  040546",
      "code_information": [
        {
          "code": "3521438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.7885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BARRIER MINOR PROTECTIVE",
      "code_information": [
        {
          "code": "3521441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.0687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT FEMORAL 111644",
      "code_information": [
        {
          "code": "3521442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.1296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACOSTOMY PROC ******",
      "code_information": [
        {
          "code": "3521523",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 207,
          "minimum": 43.47,
          "maximum": 151.5654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.8306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH CVP SL       AK-24301",
      "code_information": [
        {
          "code": "3521655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRAINAL ACCESS    INS-5HND",
      "code_information": [
        {
          "code": "3521683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2054,
          "minimum": 431.34,
          "maximum": 1503.9388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1278.348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DAILY CARE            6638",
      "code_information": [
        {
          "code": "3521745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAINAGE PLEURX    50-7510",
      "code_information": [
        {
          "code": "3521755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 512.8329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DURAPREP SURGICAL     8630",
      "code_information": [
        {
          "code": "3521756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HYPOTHERMIA \\\"KOOL KIT\\\" 900",
      "code_information": [
        {
          "code": "3521917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1792,
          "minimum": 376.32,
          "maximum": 1312.1024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1115.287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 6FR AK-09601***",
      "code_information": [
        {
          "code": "3521942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 407,
          "minimum": 85.47,
          "maximum": 298.0054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 253.3046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 8.5 AK-09803CDC",
      "code_information": [
        {
          "code": "3521947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 628,
          "minimum": 131.88,
          "maximum": 459.8216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 390.8484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGAT CONE/TUBE BX  7721",
      "code_information": [
        {
          "code": "3521963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-SARAH 2778 ALL SIZES",
      "code_information": [
        {
          "code": "3522000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 505,
          "minimum": 106.05,
          "maximum": 369.761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 314.2969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-HANNAH 2160 ALL SIZES",
      "code_information": [
        {
          "code": "3522002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 256,
          "minimum": 53.76,
          "maximum": 187.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.3267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K ALL SIZES",
      "code_information": [
        {
          "code": "3522003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 179.2426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LUMBAR PUNCTURE    4011015",
      "code_information": [
        {
          "code": "3522152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.7952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MAC CATH MULTI AK-21242CDC",
      "code_information": [
        {
          "code": "3522182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1364,
          "minimum": 286.44,
          "maximum": 998.7208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 848.9127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 20FR         6820",
      "code_information": [
        {
          "code": "3522270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 439.3932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00568241",
      "code_information": [
        {
          "code": "3522271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 439.3932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KOOL NEONATAL 950",
      "code_information": [
        {
          "code": "3522460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1169,
          "minimum": 245.49,
          "maximum": 855.9418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 727.5505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING ALL",
      "code_information": [
        {
          "code": "3522465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.9081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-MORGAN LTX-FREE    MT2000",
      "code_information": [
        {
          "code": "3522687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 448,
          "minimum": 94.08,
          "maximum": 328.0256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 278.8218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-4-WAY         4238701",
      "code_information": [
        {
          "code": "3523121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND PREMATURE 900643",
      "code_information": [
        {
          "code": "3523139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND MICRO     900644",
      "code_information": [
        {
          "code": "3523140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 50MM    RD805-10",
      "code_information": [
        {
          "code": "3523187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 101,
          "minimum": 21.21,
          "maximum": 73.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.8594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MITT-HAND CONTROL PR  M2023V-A",
      "code_information": [
        {
          "code": "3523675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.9635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTRAOSSEOUS ORANGE",
      "code_information": [
        {
          "code": "3523854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATN     ALL 7700's",
      "code_information": [
        {
          "code": "3523864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.1296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX11C",
      "code_information": [
        {
          "code": "3525447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X13.8 C1616A",
      "code_information": [
        {
          "code": "3525465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 161.1938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X7.8  C1610A",
      "code_information": [
        {
          "code": "3525466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X7.8  C2010A",
      "code_information": [
        {
          "code": "3525467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "3525468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL STR 17GX4-1/2\\\"",
      "code_information": [
        {
          "code": "3525873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 20G X 1\\\"",
      "code_information": [
        {
          "code": "3525882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS G04153",
      "code_information": [
        {
          "code": "3525915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 857,
          "minimum": 179.97,
          "maximum": 627.4954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 533.3711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-4   DJ4011X",
      "code_information": [
        {
          "code": "3525924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 152.4806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL PENCAN    333866",
      "code_information": [
        {
          "code": "3525950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX5\\\"    405148",
      "code_information": [
        {
          "code": "3525951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.9291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX7\\\"    405149",
      "code_information": [
        {
          "code": "3525960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X22G",
      "code_information": [
        {
          "code": "3525975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.1041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X25G",
      "code_information": [
        {
          "code": "3525976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PROBLOC 20X100 HN3S-100",
      "code_information": [
        {
          "code": "3526110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E CATH PLUS 241285-41E",
      "code_information": [
        {
          "code": "3526122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 467,
          "minimum": 98.07,
          "maximum": 341.9374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 290.6468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POLYLOOP-LIGATING DEVICE HX-40",
      "code_information": [
        {
          "code": "3526123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 601.2094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PULSAVAC 00-5150-182-00",
      "code_information": [
        {
          "code": "3526127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL EXTEND 480422",
      "code_information": [
        {
          "code": "3526149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3703,
          "minimum": 777.63,
          "maximum": 2711.3366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2304.6361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-AIRWAY EMMA 17448",
      "code_information": [
        {
          "code": "3526175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.3134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.5/2.8",
      "code_information": [
        {
          "code": "3526179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1520,
          "minimum": 319.2,
          "maximum": 1112.944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 946.0024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO xxXxxMM 2.0",
      "code_information": [
        {
          "code": "3526182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.7753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 5800-8-125",
      "code_information": [
        {
          "code": "3526187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1120,
          "minimum": 235.2,
          "maximum": 820.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 697.0544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.3MM TWIST QC",
      "code_information": [
        {
          "code": "3526189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT,-NIFOMETER 10-340-03",
      "code_information": [
        {
          "code": "3526194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.1241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-NASAL AUTOMATION MAD300",
      "code_information": [
        {
          "code": "3526195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 70143061",
      "code_information": [
        {
          "code": "3526216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.7608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT BUTTERFLY 240073",
      "code_information": [
        {
          "code": "3526217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER SB4000SA",
      "code_information": [
        {
          "code": "3526218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1162,
          "minimum": 244.02,
          "maximum": 850.8164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 723.1939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SB4040SC",
      "code_information": [
        {
          "code": "3526219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 807.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MALLEABLE MS4000SC",
      "code_information": [
        {
          "code": "3526220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1330,
          "minimum": 279.3,
          "maximum": 973.826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 827.7521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y936H",
      "code_information": [
        {
          "code": "3526223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CANNULATED 2.0X120MM",
      "code_information": [
        {
          "code": "3526239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1136,
          "minimum": 238.56,
          "maximum": 831.7792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 707.0123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICYRL-4-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X36",
      "code_information": [
        {
          "code": "3526256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X96",
      "code_information": [
        {
          "code": "3526257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.4817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-0 PDS PLUS 1X60",
      "code_information": [
        {
          "code": "3526258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.5936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 12X18",
      "code_information": [
        {
          "code": "3526259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-4-0 PLUS 1X18",
      "code_information": [
        {
          "code": "3526264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRILL 2.0 SPEED HAND WRIS",
      "code_information": [
        {
          "code": "3526271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1740.1465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM   70890830",
      "code_information": [
        {
          "code": "3526275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM ANTERIOR",
      "code_information": [
        {
          "code": "3526278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 595,
          "minimum": 124.95,
          "maximum": 435.659,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 370.3101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM     70890832",
      "code_information": [
        {
          "code": "3526280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 119,
          "minimum": 24.99,
          "maximum": 87.1318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT LMA ALL SIZE",
      "code_information": [
        {
          "code": "3526297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURAGAIN SIZE 4",
      "code_information": [
        {
          "code": "3526298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREADED AR-13226T",
      "code_information": [
        {
          "code": "3526314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 930,
          "minimum": 195.3,
          "maximum": 680.946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 578.8041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BATTERY 1.5 50-1010",
      "code_information": [
        {
          "code": "3526343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 919,
          "minimum": 192.99,
          "maximum": 672.8918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 571.958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL EPISTAX 10CM",
      "code_information": [
        {
          "code": "3526349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 291.8915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC SUPER AK-24301-SK",
      "code_information": [
        {
          "code": "3526356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 684,
          "minimum": 143.64,
          "maximum": 500.8248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 425.7011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY 351-3500SZ",
      "code_information": [
        {
          "code": "3526357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 946,
          "minimum": 198.66,
          "maximum": 692.6612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 588.762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 115” Y 1637101",
      "code_information": [
        {
          "code": "3526361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LITHOTOMY DYNJ31774G",
      "code_information": [
        {
          "code": "3526362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 789,
          "minimum": 165.69,
          "maximum": 577.7058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 491.0499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER CLOSED 4MM STRT",
      "code_information": [
        {
          "code": "3526366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1269,
          "minimum": 266.49,
          "maximum": 929.1618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 789.7875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAL, X",
      "code_information": [
        {
          "code": "3526388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 528,
          "minimum": 110.88,
          "maximum": 386.6016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 328.6114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAl LG",
      "code_information": [
        {
          "code": "3526389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 528,
          "minimum": 110.88,
          "maximum": 386.6016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 328.6114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-METATRSAL 20MM",
      "code_information": [
        {
          "code": "3526404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1879.5574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.2X1.8X87MM",
      "code_information": [
        {
          "code": "3526414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CANN 2.2 A-2716",
      "code_information": [
        {
          "code": "3526415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2846,
          "minimum": 597.66,
          "maximum": 2083.8412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1771.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 20GX6 405211",
      "code_information": [
        {
          "code": "3526416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.0199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL 7 SP-78107",
      "code_information": [
        {
          "code": "3526419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1023,
          "minimum": 214.83,
          "maximum": 749.0406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 636.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BASIC BREAST DYNJ60139",
      "code_information": [
        {
          "code": "3526420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-GEN VASCULAR DYNJ60177",
      "code_information": [
        {
          "code": "3526422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1556,
          "minimum": 326.76,
          "maximum": 1139.3032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 968.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC SIE DYNJ905699",
      "code_information": [
        {
          "code": "3526423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1952,
          "minimum": 409.92,
          "maximum": 1429.2544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1214.8662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO SHOULDER DYNJ60141",
      "code_information": [
        {
          "code": "3526425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 477.3578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO KNEE DYNJ60140",
      "code_information": [
        {
          "code": "3526428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 382.1352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-LOW FLOW,DISP PATIENT",
      "code_information": [
        {
          "code": "3526443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 624.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HIGH FLOW, DISP PT'",
      "code_information": [
        {
          "code": "3526445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1053,
          "minimum": 221.13,
          "maximum": 771.0066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 655.3556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SMALL PED NASAL OXYGEN",
      "code_information": [
        {
          "code": "3526446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.2093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-PED/ADULT SM – MP1500",
      "code_information": [
        {
          "code": "3526447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.2093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIGH FLOW ADULT MA1700",
      "code_information": [
        {
          "code": "3526449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INFANT OVER THE EAR",
      "code_information": [
        {
          "code": "3526455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORPEDO-4.0MM X13 CM AR-8400T",
      "code_information": [
        {
          "code": "3526458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 930,
          "minimum": 195.3,
          "maximum": 680.946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 578.8041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ABLATOR-ASPIRATING AR-8921",
      "code_information": [
        {
          "code": "3526459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.1785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR COLD 10MM Rnd",
      "code_information": [
        {
          "code": "3526467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-OVAL FLUSH-CUT AR-8550FOS",
      "code_information": [
        {
          "code": "3526471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 490.4276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOLVE-CUT RESIST XL520036000",
      "code_information": [
        {
          "code": "3526473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 512.8329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE/BLACK 1.5MM",
      "code_information": [
        {
          "code": "3526474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-90 DEG APOLLO AR-9811",
      "code_information": [
        {
          "code": "3526476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.1785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELITE IRRIG 5407010470",
      "code_information": [
        {
          "code": "3526484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 482.9591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRING-MR EMPOWERCTA",
      "code_information": [
        {
          "code": "3526487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.5858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 12 DPSB 60707010200",
      "code_information": [
        {
          "code": "3526492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 176.1307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPSB 60707010300",
      "code_information": [
        {
          "code": "3526493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPSB 60707010400",
      "code_information": [
        {
          "code": "3526494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 216.5848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPDB 60708010300",
      "code_information": [
        {
          "code": "3526495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 291.8915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 260715",
      "code_information": [
        {
          "code": "3526503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TUBING MXB-T",
      "code_information": [
        {
          "code": "3526520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 506,
          "minimum": 106.26,
          "maximum": 370.4932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 314.9192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-FLOTRAX PERFUSION 84\\\" M",
      "code_information": [
        {
          "code": "3526525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2947,
          "minimum": 618.87,
          "maximum": 2157.7934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1834.1244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT YG-272T",
      "code_information": [
        {
          "code": "3526528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.5MMX13CM AR-8550EX",
      "code_information": [
        {
          "code": "3526571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 282.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BULLET CUTTING 3MM",
      "code_information": [
        {
          "code": "3526591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2519,
          "minimum": 528.99,
          "maximum": 1844.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1567.75,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MAJOR HEAD/NEC DYNJ38985A",
      "code_information": [
        {
          "code": "3526665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 696,
          "minimum": 146.16,
          "maximum": 509.6112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 433.1695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR HEAD/NECK",
      "code_information": [
        {
          "code": "3526670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 377,
          "minimum": 79.17,
          "maximum": 276.0394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 234.6335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-BIOPATCH CHG 1”X4MM 4150",
      "code_information": [
        {
          "code": "3526904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-JAW TISSUE ENSEAL LRG",
      "code_information": [
        {
          "code": "3526926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2829,
          "minimum": 594.09,
          "maximum": 2071.3938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1760.6847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT SMALL",
      "code_information": [
        {
          "code": "3526929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 571,
          "minimum": 119.91,
          "maximum": 418.0862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 355.3733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT LARGE",
      "code_information": [
        {
          "code": "3526930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 660,
          "minimum": 138.6,
          "maximum": 483.252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 410.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A443",
      "code_information": [
        {
          "code": "3526935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 244.5914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A445",
      "code_information": [
        {
          "code": "3526936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFX 2-0 SXMP1B413",
      "code_information": [
        {
          "code": "3526938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 352,
          "minimum": 73.92,
          "maximum": 257.7344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 219.0742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4FUSION 2.0 CALIBRATED",
      "code_information": [
        {
          "code": "3526943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1113,
          "minimum": 233.73,
          "maximum": 814.9386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.6978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-AFFINITY MANIFOLD 1S85R1",
      "code_information": [
        {
          "code": "3526965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COMP SPEEDARC 11X15X13MM",
      "code_information": [
        {
          "code": "3526978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5134,
          "minimum": 1078.14,
          "maximum": 3759.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3195.2476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7.5CM POST",
      "code_information": [
        {
          "code": "3526995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 608,
          "minimum": 127.68,
          "maximum": 445.1776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 378.401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING DISP EXT 5450850003",
      "code_information": [
        {
          "code": "3526996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1879,
          "minimum": 394.59,
          "maximum": 1375.8038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1169.4332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINDER-DISP SUCT CAN",
      "code_information": [
        {
          "code": "3526997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIAMETER-STRAIGHT 5450800309",
      "code_information": [
        {
          "code": "3526999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3756,
          "minimum": 788.76,
          "maximum": 2750.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2337.6217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRICOTHYROIDOTOMY EMERGENT",
      "code_information": [
        {
          "code": "3527020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1028,
          "minimum": 215.88,
          "maximum": 752.7016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 639.7964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR GYN DYNJ60136",
      "code_information": [
        {
          "code": "3527022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 558,
          "minimum": 117.18,
          "maximum": 408.5676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.2825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-2.7MM 311.26",
      "code_information": [
        {
          "code": "3527056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 864,
          "minimum": 181.44,
          "maximum": 632.6208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 537.7277,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.15, 1.5MM",
      "code_information": [
        {
          "code": "3527057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.19, 2.0MM",
      "code_information": [
        {
          "code": "3527058",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 849,
          "minimum": 178.29,
          "maximum": 621.6378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 528.3921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SUCTION 12.7 HI CAPACITY",
      "code_information": [
        {
          "code": "3527060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X .75”",
      "code_information": [
        {
          "code": "3527066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.35X50X101MM",
      "code_information": [
        {
          "code": "3527084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.7753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-BIOPSY MARQUEE",
      "code_information": [
        {
          "code": "3527097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 484.8262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PICK-VEIN 6541",
      "code_information": [
        {
          "code": "3527102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.0/2.3",
      "code_information": [
        {
          "code": "3527119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1520,
          "minimum": 319.2,
          "maximum": 1112.944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 946.0024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO",
      "code_information": [
        {
          "code": "3527121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.7753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BRUSH ALGER 0.5MM",
      "code_information": [
        {
          "code": "3527123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.3699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOPATCH-DRESS CHG 1” X 7MM",
      "code_information": [
        {
          "code": "3527124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLENOID DRILL 2.5MM",
      "code_information": [
        {
          "code": "3527142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8074,
          "minimum": 1695.54,
          "maximum": 5911.7828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5025.0154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD WIDE MT-APUW",
      "code_information": [
        {
          "code": "3527145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 290.0244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLUS-VIVAER ARC DISP CAT500",
      "code_information": [
        {
          "code": "3527147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9026,
          "minimum": 1895.46,
          "maximum": 6608.8372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5617.5116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-KEITH FREE 1827-2.5DC",
      "code_information": [
        {
          "code": "3527159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3MM AR-8930D-13",
      "code_information": [
        {
          "code": "3527163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-GONIO SURG OSIG",
      "code_information": [
        {
          "code": "3527169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO V4608-20",
      "code_information": [
        {
          "code": "3527175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.7265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 3.2X125MM GRAY",
      "code_information": [
        {
          "code": "3527179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1195,
          "minimum": 250.95,
          "maximum": 874.979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 743.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-POSEY SECURE INFANT PED",
      "code_information": [
        {
          "code": "3527200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 242.1019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-INDIGO 140CM CATRXKIT",
      "code_information": [
        {
          "code": "3527201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5055.5115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPERATOR-C4 PENUMBRA SEPC4",
      "code_information": [
        {
          "code": "3527202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4654,
          "minimum": 977.34,
          "maximum": 3407.6588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2896.51,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENGINE INDIGO IAPS3",
      "code_information": [
        {
          "code": "3527203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1503.6459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VPEP 510",
      "code_information": [
        {
          "code": "3527204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 290.0244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRVO2-TUBE CHAMBER KIT, 900PT",
      "code_information": [
        {
          "code": "3527205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 730,
          "minimum": 153.3,
          "maximum": 534.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 454.3301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN W/AO 5.0MM",
      "code_information": [
        {
          "code": "3527232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 303.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-QUICK CONN DRVR-UQC-T10",
      "code_information": [
        {
          "code": "3527241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1399,
          "minimum": 293.79,
          "maximum": 1024.3478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 870.6956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7X70MM IJS-CDC-2770",
      "code_information": [
        {
          "code": "3527242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1733.3004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERES-PASSIVE 8801075",
      "code_information": [
        {
          "code": "3527246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.9X10X61MM",
      "code_information": [
        {
          "code": "3527253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.7753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DRILL SELF HOLD",
      "code_information": [
        {
          "code": "3527257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2110,
          "minimum": 443.1,
          "maximum": 1544.942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1313.2007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE 108984",
      "code_information": [
        {
          "code": "3527264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO MICRO 0",
      "code_information": [
        {
          "code": "3527266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 403.9181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3527268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5424,
          "minimum": 1139.04,
          "maximum": 3971.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3375.7349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-STERILE PGH 396985",
      "code_information": [
        {
          "code": "3527269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-BS IS-1 330834",
      "code_information": [
        {
          "code": "3527270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 7MM, 70X",
      "code_information": [
        {
          "code": "3527281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 440.0156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-301-CG 343586",
      "code_information": [
        {
          "code": "3527282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIDER TS101DC",
      "code_information": [
        {
          "code": "3527287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 594,
          "minimum": 124.74,
          "maximum": 434.9268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 369.6878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM 7089-0832",
      "code_information": [
        {
          "code": "3527289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.0831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 1.27MM",
      "code_information": [
        {
          "code": "3527290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER DS2C026",
      "code_information": [
        {
          "code": "3527342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4316,
          "minimum": 906.36,
          "maximum": 3160.1752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2686.1489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ALLEN 3.0MM 904-0030",
      "code_information": [
        {
          "code": "3527343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 375,
          "minimum": 78.75,
          "maximum": 274.575,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 233.3887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3527395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.0199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAXI-THERM LITE 871*******",
      "code_information": [
        {
          "code": "3527520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.6567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-CALAZIME REMEDY 4 OZ",
      "code_information": [
        {
          "code": "3527567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-K SOFT 117464",
      "code_information": [
        {
          "code": "3527806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 60-S FIRM 119291",
      "code_information": [
        {
          "code": "3527807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-C MEDIUM 342657",
      "code_information": [
        {
          "code": "3527808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-INFANT POSITIONER",
      "code_information": [
        {
          "code": "3527875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 122.6069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CRM DYNJ62070",
      "code_information": [
        {
          "code": "3527887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 756,
          "minimum": 158.76,
          "maximum": 553.5432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 470.5117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-INFANT FULL BODY",
      "code_information": [
        {
          "code": "3527890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1059,
          "minimum": 222.39,
          "maximum": 775.3998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 659.0898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNCK SLCT980010",
      "code_information": [
        {
          "code": "3527947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-IRR SUCT 5500-573-000",
      "code_information": [
        {
          "code": "3527977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3127,
          "minimum": 656.67,
          "maximum": 2289.5894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1946.151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION 5450-851-012",
      "code_information": [
        {
          "code": "3527978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MICRO-IQ 12CM 5500-25S-309",
      "code_information": [
        {
          "code": "3527979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5094,
          "minimum": 1069.74,
          "maximum": 3729.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3170.3528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STD-12CM 5500-25S-307",
      "code_information": [
        {
          "code": "3527980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4754,
          "minimum": 998.34,
          "maximum": 3480.8788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2958.747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRACUDA-12CM IQ 5500-25S-310",
      "code_information": [
        {
          "code": "3527981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5201,
          "minimum": 1092.21,
          "maximum": 3808.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3236.9464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND ROYLAN RT MED",
      "code_information": [
        {
          "code": "3528086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORTHOSIS-ANKLE FOOT LG",
      "code_information": [
        {
          "code": "3528101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 704,
          "minimum": 147.84,
          "maximum": 515.4688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 438.1485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 30 DPSB 60707010500",
      "code_information": [
        {
          "code": "3529495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPDB 60708010200",
      "code_information": [
        {
          "code": "3529498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 428,
          "minimum": 89.88,
          "maximum": 313.3816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 266.3744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SINGLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 396.4497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST DOUBLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 468,
          "minimum": 98.28,
          "maximum": 342.6696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 291.2692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #4     4DCP",
      "code_information": [
        {
          "code": "3533309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #6,8,10 DCP",
      "code_information": [
        {
          "code": "3533315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SKIN TEMP DISP MU11228",
      "code_information": [
        {
          "code": "3533577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP ISOLETTE    MU12551",
      "code_information": [
        {
          "code": "3533578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.1241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-RECTAL/ESOPH ST     491B",
      "code_information": [
        {
          "code": "3533590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTANT-SKIN REMEDY 2 OZ",
      "code_information": [
        {
          "code": "3536085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-SKIN NO STING    MSC1528",
      "code_information": [
        {
          "code": "3536099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.3765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-EYE FOAM       28300",
      "code_information": [
        {
          "code": "3536100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-JP 100ML  SU130-1305",
      "code_information": [
        {
          "code": "3538200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3539345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INITIATION BREAST MILK 673",
      "code_information": [
        {
          "code": "3539346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 356,
          "minimum": 74.76,
          "maximum": 260.6632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 221.5637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-MANUAL HARMONY 67186S",
      "code_information": [
        {
          "code": "3539347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-BIS QUATTRO    186-0106",
      "code_information": [
        {
          "code": "3541300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 336,
          "minimum": 70.56,
          "maximum": 246.0192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 209.1163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS PED DISP",
      "code_information": [
        {
          "code": "3541324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.2437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS ADLT DISP",
      "code_information": [
        {
          "code": "3541325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.2437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SKIN HNICU38",
      "code_information": [
        {
          "code": "3541328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-ACOUSTIC RESPIRATION",
      "code_information": [
        {
          "code": "3541329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 209.7387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RECIP PLATELET     4C-2100",
      "code_information": [
        {
          "code": "3541430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD FILTRATION   4020005",
      "code_information": [
        {
          "code": "3541446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.1108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BURETROL 150ML",
      "code_information": [
        {
          "code": "3541503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 252,
          "minimum": 52.92,
          "maximum": 184.5144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.8372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW RADIAL ARTERY",
      "code_information": [
        {
          "code": "3541912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP Y FOR BLOOD IV  D-100",
      "code_information": [
        {
          "code": "3541945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 530.2592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DIALYZER EXELTRA    5M2119",
      "code_information": [
        {
          "code": "3541947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 292,
          "minimum": 61.32,
          "maximum": 213.8024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 181.732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3541950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1539,
          "minimum": 323.19,
          "maximum": 1126.8558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 957.8274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FEMORAL ART  C-PMS-401J-FA",
      "code_information": [
        {
          "code": "3542127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO ALL SZ W/ STABILIZER",
      "code_information": [
        {
          "code": "3542128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1489,
          "minimum": 312.69,
          "maximum": 1090.2458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 926.7089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER HF 1000 PRISMAFLEX",
      "code_information": [
        {
          "code": "3542131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2248,
          "minimum": 472.08,
          "maximum": 1645.9856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1399.0878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION OSTOMY BX 1500H",
      "code_information": [
        {
          "code": "3542454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 110 INFUSION 1635101",
      "code_information": [
        {
          "code": "3542760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.9081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRISMAFLEX TPE2000 114093",
      "code_information": [
        {
          "code": "3542806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2271,
          "minimum": 476.91,
          "maximum": 1662.8262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1413.4023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RADIAL ARTERY C-PMS-301-RA",
      "code_information": [
        {
          "code": "3543008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORACENTESIS      4653-48",
      "code_information": [
        {
          "code": "3543530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TUR IRRIGATION  06543-01",
      "code_information": [
        {
          "code": "3543551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE REPOSITION",
      "code_information": [
        {
          "code": "3543681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 497,
          "minimum": 104.37,
          "maximum": 363.9034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.3179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE XL REPOSITION",
      "code_information": [
        {
          "code": "3543685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 492.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE SM   2042-01",
      "code_information": [
        {
          "code": "3543730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE LRG  2042-03",
      "code_information": [
        {
          "code": "3543732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-NIPPLE REGULAR   67203S",
      "code_information": [
        {
          "code": "3544003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SEQ COMP KNEE      95xx",
      "code_information": [
        {
          "code": "3544619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 129.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501B",
      "code_information": [
        {
          "code": "3544638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.2082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501L",
      "code_information": [
        {
          "code": "3544639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.9358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE   VP501M",
      "code_information": [
        {
          "code": "3544640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.1108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530M",
      "code_information": [
        {
          "code": "3544645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.2082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530L",
      "code_information": [
        {
          "code": "3544650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.6556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM CHILD        8001-01",
      "code_information": [
        {
          "code": "3544659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ELEVATOR     8011-02",
      "code_information": [
        {
          "code": "3544860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE ALL SZS TX4442-0x",
      "code_information": [
        {
          "code": "3545160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.6634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE PED       9007-00",
      "code_information": [
        {
          "code": "3545177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.7542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 3L   5B9858",
      "code_information": [
        {
          "code": "3545500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 539,
          "minimum": 113.19,
          "maximum": 394.6558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 335.4574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 3L  5B9859",
      "code_information": [
        {
          "code": "3545502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 557,
          "minimum": 116.97,
          "maximum": 407.8354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 346.6601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 2L  5B9896",
      "code_information": [
        {
          "code": "3545504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 311.8074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 2L   5B9876",
      "code_information": [
        {
          "code": "3545505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.9547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIAL 1.5% 3L       5B9857",
      "code_information": [
        {
          "code": "3545515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 529,
          "minimum": 111.09,
          "maximum": 387.3338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 329.2337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 1000ML  07139-09",
      "code_information": [
        {
          "code": "3545555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 2000ML  07973-07",
      "code_information": [
        {
          "code": "3545613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 134.4319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-GYLCINE 1.5% IRRIG 3000ML",
      "code_information": [
        {
          "code": "3545747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 128.2082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML  07972-08",
      "code_information": [
        {
          "code": "3545751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.0753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 3000ML 07828-08",
      "code_information": [
        {
          "code": "3545752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.0753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML R5200-01",
      "code_information": [
        {
          "code": "3545753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 1000ML 07953-09",
      "code_information": [
        {
          "code": "3545755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.0133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-MDI ADAPTER INLINE",
      "code_information": [
        {
          "code": "3545901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.0MM 2883-02-040",
      "code_information": [
        {
          "code": "3547925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3159.7725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-BENDING 03.501.072",
      "code_information": [
        {
          "code": "3547929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1032,
          "minimum": 216.72,
          "maximum": 755.6304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 642.2858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 650.010",
      "code_information": [
        {
          "code": "3547941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM 60XL",
      "code_information": [
        {
          "code": "3547946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 420.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIXER-CEMENT 3CC 658.969S",
      "code_information": [
        {
          "code": "3547948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.601S",
      "code_information": [
        {
          "code": "3547949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1879.5574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ULTRA ACCESS 658.902S",
      "code_information": [
        {
          "code": "3547952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5359,
          "minimum": 1125.39,
          "maximum": 3923.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3335.2808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC M6275009/10",
      "code_information": [
        {
          "code": "3547958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.9291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-QUILL 2-0 YA-2034Q",
      "code_information": [
        {
          "code": "3547961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 336,
          "minimum": 70.56,
          "maximum": 246.0192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 209.1163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-4-0 PROLENE 8526H",
      "code_information": [
        {
          "code": "3547969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.0133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT",
      "code_information": [
        {
          "code": "3547970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 420.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX",
      "code_information": [
        {
          "code": "3547971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 398,
          "minimum": 83.58,
          "maximum": 291.4156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 247.7033,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY UNCUFF",
      "code_information": [
        {
          "code": "3547972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 358.4851,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 2MM AR-7523",
      "code_information": [
        {
          "code": "3547986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-ZONE NAVIGATOR AR-7900",
      "code_information": [
        {
          "code": "3547987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 650.112",
      "code_information": [
        {
          "code": "3547990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX CN",
      "code_information": [
        {
          "code": "3547997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 303.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX UN",
      "code_information": [
        {
          "code": "3547998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 402,
          "minimum": 84.42,
          "maximum": 294.3444,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 250.1927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SHILEY",
      "code_information": [
        {
          "code": "3547999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY CUFFED",
      "code_information": [
        {
          "code": "3548000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 671,
          "minimum": 140.91,
          "maximum": 491.3062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 417.6103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED  4LPC",
      "code_information": [
        {
          "code": "3548001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 626,
          "minimum": 131.46,
          "maximum": 458.3572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 389.6036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ4 S",
      "code_information": [
        {
          "code": "3548003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.3068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-TRACH 15MM DECANN WHITE",
      "code_information": [
        {
          "code": "3548004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-TRACH SZ 1 DECANN SH",
      "code_information": [
        {
          "code": "3548005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.2304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED",
      "code_information": [
        {
          "code": "3548006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 780,
          "minimum": 163.8,
          "maximum": 571.116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 485.4486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY FLEX INNER",
      "code_information": [
        {
          "code": "3548007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ1",
      "code_information": [
        {
          "code": "3548009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 75.3068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FLUENT DISP FLT-112",
      "code_information": [
        {
          "code": "3548028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1739,
          "minimum": 365.19,
          "maximum": 1273.2958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1082.3014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRESSING CHANGE 76681",
      "code_information": [
        {
          "code": "3549001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 275,
          "minimum": 57.75,
          "maximum": 201.355,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.1517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MOMOPTY 20X15 21201",
      "code_information": [
        {
          "code": "3549005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 458,
          "minimum": 96.18,
          "maximum": 335.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 285.0455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEELIFT-AFO  081531532",
      "code_information": [
        {
          "code": "3549018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 842,
          "minimum": 176.82,
          "maximum": 616.5124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 524.0355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-SUCTION NEURO NST031/25",
      "code_information": [
        {
          "code": "3549020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-SHANK MOD 5",
      "code_information": [
        {
          "code": "3549027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1879.5574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-LORDOTIC 5",
      "code_information": [
        {
          "code": "3549030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1461.9471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KVLAB3C",
      "code_information": [
        {
          "code": "3549037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.2016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KCLAB2C",
      "code_information": [
        {
          "code": "3549038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.8937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPEN 279726500",
      "code_information": [
        {
          "code": "3549047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3029,
          "minimum": 636.09,
          "maximum": 2217.8338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1885.1587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX ER VALVE REPLACEMEN",
      "code_information": [
        {
          "code": "3549059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX CATH ACCESS 50-7280",
      "code_information": [
        {
          "code": "3549060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-NAVIGATION 286750210S",
      "code_information": [
        {
          "code": "3549063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1671.0634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 020 XFR004xxx",
      "code_information": [
        {
          "code": "3549066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2903,
          "minimum": 609.63,
          "maximum": 2125.5766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1806.7401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL SND1T3 20.5",
      "code_information": [
        {
          "code": "3549069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3142.3461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-SYNC DISTAL RADIAL, SDRB-",
      "code_information": [
        {
          "code": "3549082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 252.6822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-BASIC HEEL PRESSURE",
      "code_information": [
        {
          "code": "3549107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 209.7387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- LIGHT 03.612.021S",
      "code_information": [
        {
          "code": "3549135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2191,
          "minimum": 460.11,
          "maximum": 1604.2502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1363.6127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LIGHT 03.615.132S",
      "code_information": [
        {
          "code": "3549136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1748,
          "minimum": 367.08,
          "maximum": 1279.8856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1087.9028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 388.175",
      "code_information": [
        {
          "code": "3549150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1078,
          "minimum": 226.38,
          "maximum": 789.3116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 670.9149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 9-0 V449G",
      "code_information": [
        {
          "code": "3549155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 136.9214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHALANGEAL 20MM",
      "code_information": [
        {
          "code": "3549160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1879.5574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADER-TRIAL DRG 7032ANS",
      "code_information": [
        {
          "code": "3549166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1671.0634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULAIDE-CPAP SIZE 2, CA102-",
      "code_information": [
        {
          "code": "3549182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.3134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL PRP ABS-10061T",
      "code_information": [
        {
          "code": "3549185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1357.389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.021S",
      "code_information": [
        {
          "code": "3549190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2362,
          "minimum": 496.02,
          "maximum": 1729.4564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1470.0379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703713",
      "code_information": [
        {
          "code": "3549201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1053.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TAP 12.5MM 338.17",
      "code_information": [
        {
          "code": "3549204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1663.595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- CANN 6.5MM 702603",
      "code_information": [
        {
          "code": "3549216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2032,
          "minimum": 426.72,
          "maximum": 1487.8304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1264.6558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CSG WORLEY STANDARD",
      "code_information": [
        {
          "code": "3549218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1900,
          "minimum": 399,
          "maximum": 1391.18,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1182.503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-LAT VEIN WORLEY",
      "code_information": [
        {
          "code": "3549219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2264,
          "minimum": 475.44,
          "maximum": 1657.7008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1409.0457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-UNCUFFED 7.0 70XLTUP",
      "code_information": [
        {
          "code": "3549227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 420.7221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.1X87 A-3836",
      "code_information": [
        {
          "code": "3549229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-PCL 2.4MMX10",
      "code_information": [
        {
          "code": "3549231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.2693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CROSS PLATE 705172",
      "code_information": [
        {
          "code": "3549243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2762,
          "minimum": 580.02,
          "maximum": 2022.3364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1718.9859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL CPRP ABS-10063",
      "code_information": [
        {
          "code": "3549250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1232.2926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-THREAD LOCK 03.835.009S",
      "code_information": [
        {
          "code": "3549252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1698,
          "minimum": 356.58,
          "maximum": 1243.2756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1056.7843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPEEDGUIDE-T8 2.4/2.7X30MM",
      "code_information": [
        {
          "code": "3549269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2408,
          "minimum": 505.68,
          "maximum": 1763.1376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1498.667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEEDGUIDE AO 2.0X30MM",
      "code_information": [
        {
          "code": "3549270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5577,
          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3470.9575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 2.1MM",
      "code_information": [
        {
          "code": "3549272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1742,
          "minimum": 365.82,
          "maximum": 1275.4924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1084.1685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS TRIPLE 91429",
      "code_information": [
        {
          "code": "3549278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 453,
          "minimum": 95.13,
          "maximum": 331.6866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 281.9336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.1X300MM RMT3130",
      "code_information": [
        {
          "code": "3549279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2423,
          "minimum": 508.83,
          "maximum": 1774.1206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1508.0025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-2.5 SOLID HT-2502",
      "code_information": [
        {
          "code": "3549283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 936.0445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Y-PORT-20 FR M00580641",
      "code_information": [
        {
          "code": "3549284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.6634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-DHS REAMER 338.13",
      "code_information": [
        {
          "code": "3549287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7319,
          "minimum": 1536.99,
          "maximum": 5358.9718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4555.126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOAM-BUMP 10X6X6\\\" DYNJBUMP03",
      "code_information": [
        {
          "code": "3549293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.2016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-PALM ROLYAN SOFT GEL LT",
      "code_information": [
        {
          "code": "3549295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 246,
          "minimum": 51.66,
          "maximum": 180.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 153.103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FORCEP SUCTION 9G12R",
      "code_information": [
        {
          "code": "3549304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.1805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HUMIDIFIER ATSVII BE-1010",
      "code_information": [
        {
          "code": "3549307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CATH LINE 020378801",
      "code_information": [
        {
          "code": "3549311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM 6149.1035",
      "code_information": [
        {
          "code": "3549338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 650.114",
      "code_information": [
        {
          "code": "3549348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ANGLE 14MM 684.434",
      "code_information": [
        {
          "code": "3549349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1879.5574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5M SHORT 6149.1037",
      "code_information": [
        {
          "code": "3549352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 16MM 650.116",
      "code_information": [
        {
          "code": "3549372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD BK-IS 109185",
      "code_information": [
        {
          "code": "3549411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP 2.4MM",
      "code_information": [
        {
          "code": "3549451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 204.7597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB LARGE AR-8970-09",
      "code_information": [
        {
          "code": "3549452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 877.5417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ADAPTER BIOPSY MAJ-1414",
      "code_information": [
        {
          "code": "3549507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-THUMB SPICA ANY    350S",
      "code_information": [
        {
          "code": "3549700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.9081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUICKCLOT 8X8 4010",
      "code_information": [
        {
          "code": "3549703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 647.8872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-COMFY FINGER",
      "code_information": [
        {
          "code": "3549716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 63.4817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 6 6SIC",
      "code_information": [
        {
          "code": "3549725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.5515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 8 8SIC",
      "code_information": [
        {
          "code": "3549726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.5515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUIKCLOT 5X5 4000",
      "code_information": [
        {
          "code": "3549730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 733,
          "minimum": 153.93,
          "maximum": 536.7026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 456.1972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOCN0346",
      "code_information": [
        {
          "code": "3549731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 476.113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 200 AC-10030100",
      "code_information": [
        {
          "code": "3549732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3289,
          "minimum": 690.69,
          "maximum": 2408.2058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2046.9749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ESOPHAGEAL 100001",
      "code_information": [
        {
          "code": "3549734",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BV175-6 BLUE EPM8743",
      "code_information": [
        {
          "code": "3549735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 607,
          "minimum": 127.47,
          "maximum": 444.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 377.7786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 365 AC-10030110",
      "code_information": [
        {
          "code": "3549736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1608.2041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LONG TUNNELING SC-4254",
      "code_information": [
        {
          "code": "3549742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1253.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM 03.010.061",
      "code_information": [
        {
          "code": "3549747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1751,
          "minimum": 367.71,
          "maximum": 1282.0822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1089.7699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 16MM 03.037.002",
      "code_information": [
        {
          "code": "3549748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5189,
          "minimum": 1089.69,
          "maximum": 3799.3858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3229.4779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 6-9MM 03.037.022",
      "code_information": [
        {
          "code": "3549750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3479,
          "minimum": 730.59,
          "maximum": 2547.3238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2165.2252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-BABYFLOW PLUS S DISP MP37",
      "code_information": [
        {
          "code": "3549751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.7187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-DISP",
      "code_information": [
        {
          "code": "3549752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.7819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEOMASK-CPAP",
      "code_information": [
        {
          "code": "3549753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BABUFLOE SZ 4 DISP MP0149",
      "code_information": [
        {
          "code": "3549754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 225,
          "minimum": 47.25,
          "maximum": 164.745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.0332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP",
      "code_information": [
        {
          "code": "3549755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.0266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PNEUMOTHORAX G05297",
      "code_information": [
        {
          "code": "3549757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1013,
          "minimum": 212.73,
          "maximum": 741.7186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 630.4608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOURNIQUET-TACTICAL 30-0023",
      "code_information": [
        {
          "code": "3549759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 360,
          "minimum": 75.6,
          "maximum": 263.592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.0532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R001",
      "code_information": [
        {
          "code": "3549765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1608.2041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-A003",
      "code_information": [
        {
          "code": "3549766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1984.1156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-SEATTLE PLUS MP02260",
      "code_information": [
        {
          "code": "3549776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 351.0167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE HINGED DONJOY",
      "code_information": [
        {
          "code": "3549781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 872,
          "minimum": 183.12,
          "maximum": 638.4784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 542.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-DISTAL 24MM 03.211.024",
      "code_information": [
        {
          "code": "3549786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1643.0568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PROX 24MM 03.211.124",
      "code_information": [
        {
          "code": "3549787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1643.0568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL SINGLE PK 1",
      "code_information": [
        {
          "code": "3549805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 617.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROCESSOR-SOUND LINE 90711",
      "code_information": [
        {
          "code": "3549810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-BAHA STORAGE Z342010",
      "code_information": [
        {
          "code": "3549811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-PERFORM REV PERI MWJ126",
      "code_information": [
        {
          "code": "3549818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 624.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5X220MM DWD017",
      "code_information": [
        {
          "code": "3549819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 950,
          "minimum": 199.5,
          "maximum": 695.59,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 591.2515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-0xx-000",
      "code_information": [
        {
          "code": "3549839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SHAFT 8X510 0227-8510S",
      "code_information": [
        {
          "code": "3549851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1867,
          "minimum": 392.07,
          "maximum": 1367.0174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1161.9648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LOCKING 705078",
      "code_information": [
        {
          "code": "3549854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1563,
          "minimum": 328.23,
          "maximum": 1144.4286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 972.7643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 700354",
      "code_information": [
        {
          "code": "3549867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1228,
          "minimum": 257.88,
          "maximum": 899.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 764.2704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW INFINITY 3600315",
      "code_information": [
        {
          "code": "3549870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 779.8296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.4 G3606010",
      "code_information": [
        {
          "code": "3549873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-STRAIGH TIP 2762-01-0004",
      "code_information": [
        {
          "code": "3549916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1963.5774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR NIM 945NSD2750",
      "code_information": [
        {
          "code": "3549918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAGITTAL 2296-003-155",
      "code_information": [
        {
          "code": "3549927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 2.4 1608-006-147",
      "code_information": [
        {
          "code": "3549928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 751,
          "minimum": 157.71,
          "maximum": 549.8822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 467.3999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 1MM 1608-006-151",
      "code_information": [
        {
          "code": "3549929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 722,
          "minimum": 151.62,
          "maximum": 528.6484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 449.3511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-413S1",
      "code_information": [
        {
          "code": "3549931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 7X15MM 2296-003-103",
      "code_information": [
        {
          "code": "3549932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 324.2548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-111S5",
      "code_information": [
        {
          "code": "3549933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHORT 2.5MM 2296-003-413",
      "code_information": [
        {
          "code": "3549934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 311.8074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48X70MM 2108-197-00S4",
      "code_information": [
        {
          "code": "3549935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.6556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X75MM 4125-089-075",
      "code_information": [
        {
          "code": "3549936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 737,
          "minimum": 154.77,
          "maximum": 539.6314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 458.6867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90 4125-097-090",
      "code_information": [
        {
          "code": "3549937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 372.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 13X90MM 4113-119-090",
      "code_information": [
        {
          "code": "3549938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 372.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-119-090",
      "code_information": [
        {
          "code": "3549939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 477.3578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-127-090",
      "code_information": [
        {
          "code": "3549940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 477.3578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-70X12.5MM 0277-096-277",
      "code_information": [
        {
          "code": "3549941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 572,
          "minimum": 120.12,
          "maximum": 418.8184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 355.9956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RECIPR. 0277-096-325",
      "code_information": [
        {
          "code": "3549942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 583,
          "minimum": 122.43,
          "maximum": 426.8726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 362.8417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 6125-119-090",
      "code_information": [
        {
          "code": "3549943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 832,
          "minimum": 174.72,
          "maximum": 609.1904,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 517.8118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-18.5X90.5 2108-382-003",
      "code_information": [
        {
          "code": "3549944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 618,
          "minimum": 129.78,
          "maximum": 452.4996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 384.6247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE,SAW VASC 5400-134-415",
      "code_information": [
        {
          "code": "3549951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 685,
          "minimum": 143.85,
          "maximum": 501.557,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 426.3234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE, SAW 25X90MM 6725-127-09",
      "code_information": [
        {
          "code": "3549952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2047,
          "minimum": 429.87,
          "maximum": 1498.8134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1273.9914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 8MM M0013635",
      "code_information": [
        {
          "code": "3549961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4128,
          "minimum": 866.88,
          "maximum": 3022.5216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2569.1434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SPINAL W/EPI & BUPIV 3338",
      "code_information": [
        {
          "code": "3549962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 174.2636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-VISTASEAL VSTL35",
      "code_information": [
        {
          "code": "3549965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 819,
          "minimum": 171.99,
          "maximum": 599.6718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 509.721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SUTURE UCL AR-7715-4.5",
      "code_information": [
        {
          "code": "3549968",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3921,
          "minimum": 823.41,
          "maximum": 2870.9562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2440.3128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CEMENT MIX 0206-015-000",
      "code_information": [
        {
          "code": "3549999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 351.0167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-75MM 00-5901-020-00",
      "code_information": [
        {
          "code": "3550017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2485,
          "minimum": 521.85,
          "maximum": 1819.517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1546.5894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-TIB 42-5320-064-02",
      "code_information": [
        {
          "code": "3550019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9296,
          "minimum": 1952.16,
          "maximum": 6806.5312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5785.5515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-REVERSED GLEN MWJ004",
      "code_information": [
        {
          "code": "3550025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1253.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-PRESS FIT REV DWJ002",
      "code_information": [
        {
          "code": "3550026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1671.0634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-INTERLOCKING 3MMX4CM M001",
      "code_information": [
        {
          "code": "3550029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2529,
          "minimum": 531.09,
          "maximum": 1851.7338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1573.9737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DSIP RFID EXPIRATORY MP0",
      "code_information": [
        {
          "code": "3550040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.9137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.6X30 SPEED 703894",
      "code_information": [
        {
          "code": "3550046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 937,
          "minimum": 196.77,
          "maximum": 686.0714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 583.1607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC D-BLADE",
      "code_information": [
        {
          "code": "3550048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.5571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #3 MILLER",
      "code_information": [
        {
          "code": "3550049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 150.6135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WALKER-CAM  II 55988503",
      "code_information": [
        {
          "code": "3550050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 648.5095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-2.5X7MM AR-8998DS",
      "code_information": [
        {
          "code": "3550061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.9072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 PC-5",
      "code_information": [
        {
          "code": "3550066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 18\\\" PC-3",
      "code_information": [
        {
          "code": "3550067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROS-NASAL SEPTAL ROUND SP1102",
      "code_information": [
        {
          "code": "3550072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1148.895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.007.01S",
      "code_information": [
        {
          "code": "3550083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2060,
          "minimum": 432.6,
          "maximum": 1508.332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.0822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST ALL SIZE 9105-00s",
      "code_information": [
        {
          "code": "3550085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP LRG 47800100",
      "code_information": [
        {
          "code": "3550087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1211.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP REG 47700100",
      "code_information": [
        {
          "code": "3550088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP SLIM 4760010",
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        {
          "code": "3550089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CAN 190MM 03.010.036",
      "code_information": [
        {
          "code": "3550091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3373,
          "minimum": 708.33,
          "maximum": 2469.7106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2099.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-W/F L&L PED ALL 5002s",
      "code_information": [
        {
          "code": "3550092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.0133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 6MMX10CM M00",
      "code_information": [
        {
          "code": "3550094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2529,
          "minimum": 531.09,
          "maximum": 1851.7338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1573.9737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-ANNULOTOMY 675.405S",
      "code_information": [
        {
          "code": "3550111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1671.0634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-SHIM SS 6133.0326S",
      "code_information": [
        {
          "code": "3550112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-BRILL 3.5 682.108S",
      "code_information": [
        {
          "code": "3550131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 282.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.914S",
      "code_information": [
        {
          "code": "3550136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3159.7725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CT 3.5M 6149.9135",
      "code_information": [
        {
          "code": "3550137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 617.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIABETIC FOOT CARE 0811748",
      "code_information": [
        {
          "code": "3550156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 136.9214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 71MM 705506",
      "code_information": [
        {
          "code": "3550158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1223,
          "minimum": 256.83,
          "maximum": 895.4806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 761.1585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X25MM 7005-3325",
      "code_information": [
        {
          "code": "3550159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT RSZ4001S",
      "code_information": [
        {
          "code": "3550168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1232.2926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW 1020-00-000",
      "code_information": [
        {
          "code": "3550179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-C001",
      "code_information": [
        {
          "code": "3550198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 877.5417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22GX9CM",
      "code_information": [
        {
          "code": "3550200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 252.6822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.8X122 A-3738",
      "code_information": [
        {
          "code": "3550221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIMED RX COUDE 1314ANS",
      "code_information": [
        {
          "code": "3550227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CERV MOBI-C 13X17 MB3375",
      "code_information": [
        {
          "code": "3550228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21902,
          "minimum": 4599.42,
          "maximum": 16036.6444,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13631.1477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPAR 14MM 0024-LDR",
      "code_information": [
        {
          "code": "3550229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1253.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYGEN VOCSN PRT-00930",
      "code_information": [
        {
          "code": "3550231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 244.5914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE 2.5MM 694",
      "code_information": [
        {
          "code": "3550236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5953,
          "minimum": 1250.13,
          "maximum": 4358.7866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3704.9686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-T 601.800",
      "code_information": [
        {
          "code": "3550239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3487,
          "minimum": 732.27,
          "maximum": 2553.1814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2170.2042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPANNER-WRENCH 687.509",
      "code_information": [
        {
          "code": "3550240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INSERTER 694.004",
      "code_information": [
        {
          "code": "3550241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4175,
          "minimum": 876.75,
          "maximum": 3056.935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2598.3947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-INSERTER 694.005",
      "code_information": [
        {
          "code": "3550242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2633.2475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-CALIBER GRAPHIC 994.001",
      "code_information": [
        {
          "code": "3550244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14166,
          "minimum": 2974.86,
          "maximum": 10372.3452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8816.4934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARGYLE SHUNT 8888577775",
      "code_information": [
        {
          "code": "3550249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 259.5283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND A31216",
      "code_information": [
        {
          "code": "3550250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.9403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-MEPITEL 6.8X10",
      "code_information": [
        {
          "code": "3550253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 118.8727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 12FR 1.0CM",
      "code_information": [
        {
          "code": "3550256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.0976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-I/A CAPSULGUARD",
      "code_information": [
        {
          "code": "3550264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.1728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE RT SM 70831",
      "code_information": [
        {
          "code": "3550272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 338,
          "minimum": 70.98,
          "maximum": 247.4836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 210.3611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE LT SM 70831",
      "code_information": [
        {
          "code": "3550273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-OSTEOFUZE OF-BMA-11",
      "code_information": [
        {
          "code": "3550274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8800,
          "minimum": 1848,
          "maximum": 6443.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5476.856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET REUSE",
      "code_information": [
        {
          "code": "3550275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 870,
          "minimum": 182.7,
          "maximum": 637.014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 541.4619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-HEMOSTATIC POWDER 1978",
      "code_information": [
        {
          "code": "3550278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 460.5538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R002",
      "code_information": [
        {
          "code": "3550306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1608.2041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TROCAR THORACIC 24FR SWD",
      "code_information": [
        {
          "code": "3550314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.6479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-INSPIRA BREAST SRM",
      "code_information": [
        {
          "code": "3550331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4485,
          "minimum": 941.85,
          "maximum": 3283.917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2791.3294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP 180-210CC",
      "code_information": [
        {
          "code": "3550332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DEFENDO Y-OPSY 100303",
      "code_information": [
        {
          "code": "3550394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PUSHLOCK 2.9MM",
      "code_information": [
        {
          "code": "3550395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 716.3479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM",
      "code_information": [
        {
          "code": "3550396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.1785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH 8MM 100/897/080",
      "code_information": [
        {
          "code": "3550399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 878,
          "minimum": 184.38,
          "maximum": 642.8716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 546.4409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER 8MM 100/890/080",
      "code_information": [
        {
          "code": "3550400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.6423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 18FR 897518",
      "code_information": [
        {
          "code": "3550406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 195,
          "minimum": 40.95,
          "maximum": 142.779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.3621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR 897516",
      "code_information": [
        {
          "code": "3550407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 195,
          "minimum": 40.95,
          "maximum": 142.779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.3621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-TRIPLE NEEDLE INS-5300",
      "code_information": [
        {
          "code": "3550411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4172,
          "minimum": 876.12,
          "maximum": 3054.7384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2596.5276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPIN W/ADAPTER INS-5910",
      "code_information": [
        {
          "code": "3550414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4906,
          "minimum": 1030.26,
          "maximum": 3592.1732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3053.3472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J556G",
      "code_information": [
        {
          "code": "3550419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.8937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0 770G",
      "code_information": [
        {
          "code": "3550420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 124.474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8695G",
      "code_information": [
        {
          "code": "3550421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STATLOCK-URO FOLEY FOL0105",
      "code_information": [
        {
          "code": "3550423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-REDDIE KNEE XL 08154723",
      "code_information": [
        {
          "code": "3550426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 271.9757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-BACK ROLYANFIT MESH",
      "code_information": [
        {
          "code": "3550427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.1728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-2.3MM PED SCREW 4008-00",
      "code_information": [
        {
          "code": "3550429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.7399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER",
      "code_information": [
        {
          "code": "3550432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 401.4287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING RS5200",
      "code_information": [
        {
          "code": "3550447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5472,
          "minimum": 1149.12,
          "maximum": 4006.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3405.6086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-FIXATION LG FP9000L",
      "code_information": [
        {
          "code": "3550448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 364.0865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL",
      "code_information": [
        {
          "code": "3550461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-PRIME 286750200S",
      "code_information": [
        {
          "code": "3550473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1671.0634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-MMG 2862-02-108",
      "code_information": [
        {
          "code": "3550480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1175,
          "minimum": 246.75,
          "maximum": 860.335,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 731.2848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STEM 2862-02-204",
      "code_information": [
        {
          "code": "3550481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1461.9471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 03.010.060",
      "code_information": [
        {
          "code": "3550483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1814,
          "minimum": 380.94,
          "maximum": 1328.2108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1128.9792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-120",
      "code_information": [
        {
          "code": "3550487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 626.7266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-120LP",
      "code_information": [
        {
          "code": "3550488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 596.8528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MACY BEDSIDE DELIVERY M",
      "code_information": [
        {
          "code": "3550498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 932,
          "minimum": 195.72,
          "maximum": 682.4104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 580.0488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PRESSURE OPAQUE 50P148",
      "code_information": [
        {
          "code": "3550499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH,MALE EXTERNAL",
      "code_information": [
        {
          "code": "3550511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH PEDIATRIC",
      "code_information": [
        {
          "code": "3550515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.0199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO CF DEL FGS-0635",
      "code_information": [
        {
          "code": "3550530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2212,
          "minimum": 464.52,
          "maximum": 1619.6264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1376.6824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM ST 6149.1036S",
      "code_information": [
        {
          "code": "3550541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 617.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF MED MDS601MD",
      "code_information": [
        {
          "code": "3550553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF XL MDS601BD",
      "code_information": [
        {
          "code": "3550555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT MED MDS620",
      "code_information": [
        {
          "code": "3550556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 257,
          "minimum": 53.97,
          "maximum": 188.1754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 159.9491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT LRG MDS620L",
      "code_information": [
        {
          "code": "3550557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 277,
          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 172.3965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH MED MDS630MD",
      "code_information": [
        {
          "code": "3550558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 351,
          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 218.4519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH LRG MDS630LD",
      "code_information": [
        {
          "code": "3550559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH X-LG MDS630BD",
      "code_information": [
        {
          "code": "3550560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 383,
          "minimum": 80.43,
          "maximum": 280.4326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 238.3677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT 10° TIP MLD-0068",
      "code_information": [
        {
          "code": "3550592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1963.5774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.5X350MM PK6 MLD-0301",
      "code_information": [
        {
          "code": "3550593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 741.2427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-8/13/18MM MLD-0441S",
      "code_information": [
        {
          "code": "3550594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3072.0183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIM-SPIKE BLUNT MLD-0513",
      "code_information": [
        {
          "code": "3550595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1873,
          "minimum": 393.33,
          "maximum": 1371.4106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1165.699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- DILATOR MLD-0345",
      "code_information": [
        {
          "code": "3550596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 741.2427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153207",
      "code_information": [
        {
          "code": "3550599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-THORACIC TGMR312610",
      "code_information": [
        {
          "code": "3550613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84847,
          "minimum": 17817.87,
          "maximum": 62124.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52806.2274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X12MM 03.501.762",
      "code_information": [
        {
          "code": "3550619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2487,
          "minimum": 522.27,
          "maximum": 1820.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1547.8342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX16CM",
      "code_information": [
        {
          "code": "3550630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 356.618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX16CM",
      "code_information": [
        {
          "code": "3550631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICAL SCREW 3603-00-TE",
      "code_information": [
        {
          "code": "3550634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.7399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PEDIATRIC YG-232T",
      "code_information": [
        {
          "code": "3550638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.9557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT LARGE YG-282T",
      "code_information": [
        {
          "code": "3550639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 118.8727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC 153509",
      "code_information": [
        {
          "code": "3550645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3ML 165810",
      "code_information": [
        {
          "code": "3550646",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-MARKING ROBOTIP INFARED",
      "code_information": [
        {
          "code": "3550649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE F/MRI SQK65VS",
      "code_information": [
        {
          "code": "3550657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE,FLEX FLEX-200-QFT",
      "code_information": [
        {
          "code": "3550658",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.2437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 0200-20",
      "code_information": [
        {
          "code": "3550659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 861.3601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE 24F 5CC 0",
      "code_information": [
        {
          "code": "3550665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 170,
          "minimum": 35.7,
          "maximum": 124.474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.8029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ASSEMBLY DISP 83030-1",
      "code_information": [
        {
          "code": "3550668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1576,
          "minimum": 330.96,
          "maximum": 1153.9472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 980.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY 18G ANG 221251",
      "code_information": [
        {
          "code": "3550683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.7331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-BONE 3.8X13CM AR-8380BC",
      "code_information": [
        {
          "code": "3550684",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 490.4276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VS-1 5FR 80CM BEACON TIP",
      "code_information": [
        {
          "code": "3550691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 213.4729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL DETACHMENT RH1",
      "code_information": [
        {
          "code": "3550699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 994.5473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE D9212",
      "code_information": [
        {
          "code": "3550703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1077,
          "minimum": 226.17,
          "maximum": 788.5794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 670.2925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SMARTRELEASE ONYX 83030-",
      "code_information": [
        {
          "code": "3550710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1969,
          "minimum": 413.49,
          "maximum": 1441.7018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1225.4465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM 2.3MM 2862-02-201",
      "code_information": [
        {
          "code": "3550713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3171,
          "minimum": 665.91,
          "maximum": 2321.8062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1973.5353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE ULTRASOUND 8’ CVC6",
      "code_information": [
        {
          "code": "3550720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.1805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BONE HARVEST 03.404.000S",
      "code_information": [
        {
          "code": "3550737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12726,
          "minimum": 2672.46,
          "maximum": 9317.9772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7920.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MENISCAL ROOT 71935068",
      "code_information": [
        {
          "code": "3550740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5252,
          "minimum": 1102.92,
          "maximum": 3845.5144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3268.6872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-REAMER",
      "code_information": [
        {
          "code": "3550752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3893,
          "minimum": 817.53,
          "maximum": 2850.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2422.8864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXY ADULT ETCO2 OM-2125-8",
      "code_information": [
        {
          "code": "3550753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXYTYKE INFNT W/7’ TUBING",
      "code_information": [
        {
          "code": "3550754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONET 188MM 1563-00",
      "code_information": [
        {
          "code": "3550760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1253.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT INTERSTIM 3560022",
      "code_information": [
        {
          "code": "3550762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1631,
          "minimum": 342.51,
          "maximum": 1194.2182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1015.0855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 3MM BIT DK-300",
      "code_information": [
        {
          "code": "3550765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2326,
          "minimum": 488.46,
          "maximum": 1703.0972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1447.6326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DECOMPRESSION ZZ-0056",
      "code_information": [
        {
          "code": "3550777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.2924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,LASER TRACH",
      "code_information": [
        {
          "code": "3550778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 675.725S",
      "code_information": [
        {
          "code": "3550783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5055.5115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP THR 1.35M",
      "code_information": [
        {
          "code": "3550793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0 8762H",
      "code_information": [
        {
          "code": "3550794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (15) 8800966",
      "code_information": [
        {
          "code": "3550803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (5) 8801002",
      "code_information": [
        {
          "code": "3550804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 209.7387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 4.6X220 P99-110-4622",
      "code_information": [
        {
          "code": "3550805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1591,
          "minimum": 334.11,
          "maximum": 1164.9302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 990.1907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110MM 213524",
      "code_information": [
        {
          "code": "3550809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 588.1396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM ADJ 2862-02-200",
      "code_information": [
        {
          "code": "3550815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3171,
          "minimum": 665.91,
          "maximum": 2321.8062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1973.5353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.1X50 M-R 01-7141",
      "code_information": [
        {
          "code": "3550816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1472,
          "minimum": 309.12,
          "maximum": 1077.7984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 916.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL EMBOLIZATION PODH1",
      "code_information": [
        {
          "code": "3550822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 994.5473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 AO A-8004.03",
      "code_information": [
        {
          "code": "3550830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1879,
          "minimum": 394.59,
          "maximum": 1375.8038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1169.4332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 16FR PEDS 8016",
      "code_information": [
        {
          "code": "3550842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CLEARCUT 5X13 AR-8500COS",
      "code_information": [
        {
          "code": "3550848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 490.4276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.45MM SM 45303145",
      "code_information": [
        {
          "code": "3550850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAGE-12MM/8° 50/18 LUI81249",
      "code_information": [
        {
          "code": "3550854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 19856,
          "minimum": 4169.76,
          "maximum": 14538.5632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 12357.7787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-CUSTOM MED PK623984",
      "code_information": [
        {
          "code": "3550856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52648,
          "minimum": 11056.08,
          "maximum": 38548.8656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32766.5358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BAL RX DC-RYxxxxxx",
      "code_information": [
        {
          "code": "3550857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-R2P MISAGO SXRxxxxxx",
      "code_information": [
        {
          "code": "3550858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4415,
          "minimum": 927.15,
          "maximum": 3232.663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2747.7636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-METACROSS BD-xxxxxxxx",
      "code_information": [
        {
          "code": "3550859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1850,
          "minimum": 388.5,
          "maximum": 1354.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1151.3845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT F/2.16MM 3560030",
      "code_information": [
        {
          "code": "3550864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-INTERPULSE",
      "code_information": [
        {
          "code": "3550869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-SKULL MOUNT 9735300",
      "code_information": [
        {
          "code": "3550873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1643,
          "minimum": 345.03,
          "maximum": 1203.0046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1022.5539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16FR A3",
      "code_information": [
        {
          "code": "3550876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 271.9757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0X150MM 705234",
      "code_information": [
        {
          "code": "3550888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 903,
          "minimum": 189.63,
          "maximum": 661.1766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 562.0001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PERFORATED FUNCTIONAL 0",
      "code_information": [
        {
          "code": "3550898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 179.2426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-HI-SPEED 4X11 1884068HS",
      "code_information": [
        {
          "code": "3550911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2381,
          "minimum": 500.01,
          "maximum": 1743.3682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1481.863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PROLAPSE HEM3335",
      "code_information": [
        {
          "code": "3550912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2317,
          "minimum": 486.57,
          "maximum": 1696.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1442.0313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM XT SIGTRSB60AXT",
      "code_information": [
        {
          "code": "3550915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3076,
          "minimum": 645.96,
          "maximum": 2252.2472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1914.4101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM MT SIGTRSB60AMT",
      "code_information": [
        {
          "code": "3550916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1587.6659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3551250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.0687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PRECISE SKIN      DS-5",
      "code_information": [
        {
          "code": "3552655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT  STR 35R",
      "code_information": [
        {
          "code": "3552730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.5515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3552731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3552732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXW35",
      "code_information": [
        {
          "code": "3552737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.2647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKING-COMPRESSION CUSTOM",
      "code_information": [
        {
          "code": "3553701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 372.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-BONE",
      "code_information": [
        {
          "code": "3554025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9164,
          "minimum": 1924.44,
          "maximum": 6709.8808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5703.3987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CLAVICAL ADULT ALL 3001s",
      "code_information": [
        {
          "code": "3554085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.3976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "3554974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.6423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3554981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 259.5283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-1/2\\\"X2\\\" SMALL    1955",
      "code_information": [
        {
          "code": "3555059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 216.5848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2\\\"X14\\\" LARGE     1951",
      "code_information": [
        {
          "code": "3555109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 492.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2 X 3 MEDIUM     1953",
      "code_information": [
        {
          "code": "3555158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 489,
          "minimum": 102.69,
          "maximum": 358.0458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.3389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP MED  202549",
      "code_information": [
        {
          "code": "3555307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP LG   202636",
      "code_information": [
        {
          "code": "3555315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORIE-XLGE 202612&201352",
      "code_information": [
        {
          "code": "3555323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 493,
          "minimum": 103.53,
          "maximum": 360.9746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 306.8284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       G121H",
      "code_information": [
        {
          "code": "3555374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0 FS-2   636H",
      "code_information": [
        {
          "code": "3555390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.2237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-DEXON           7618-41",
      "code_information": [
        {
          "code": "3556875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 43,
          "minimum": 9.03,
          "maximum": 31.4846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 26.7619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0   1663H",
      "code_information": [
        {
          "code": "3557098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 41,
          "minimum": 8.61,
          "maximum": 30.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 25.5172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3557628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.2237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 6-0 P1       697G",
      "code_information": [
        {
          "code": "3557898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        698H",
      "code_information": [
        {
          "code": "3557956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        990H",
      "code_information": [
        {
          "code": "3558678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685G",
      "code_information": [
        {
          "code": "3558679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 16,
          "minimum": 3.36,
          "maximum": 11.7152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 9.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1653-G",
      "code_information": [
        {
          "code": "3558947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1663-H",
      "code_information": [
        {
          "code": "3558970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 49,
          "minimum": 10.29,
          "maximum": 35.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 30.4961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0       1667G",
      "code_information": [
        {
          "code": "3558978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 3-0       1669H",
      "code_information": [
        {
          "code": "3558982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4.5MM 080-453",
      "code_information": [
        {
          "code": "3559003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE P99-930-2108",
      "code_information": [
        {
          "code": "3559011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3368,
          "minimum": 707.28,
          "maximum": 2466.0496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2096.1422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND 2.5MM 1882569HS",
      "code_information": [
        {
          "code": "3559015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1938,
          "minimum": 406.98,
          "maximum": 1419.0036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1206.1531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       G695G",
      "code_information": [
        {
          "code": "3559030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1696-G",
      "code_information": [
        {
          "code": "3559036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON           1698G",
      "code_information": [
        {
          "code": "3559069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM MT SIGTRSB45AMT",
      "code_information": [
        {
          "code": "3559071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2310,
          "minimum": 485.1,
          "maximum": 1691.382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.6747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FEMALE EXT PWF-030K",
      "code_information": [
        {
          "code": "3559082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 92.1108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-LONG 4.2MM 703545",
      "code_information": [
        {
          "code": "3559085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3448,
          "minimum": 724.08,
          "maximum": 2524.6256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2145.9318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-5X100MM FIX UNVCA5STF",
      "code_information": [
        {
          "code": "3559095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 156,
          "minimum": 32.76,
          "maximum": 114.2232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 97.0897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 15MM ONB15STF",
      "code_information": [
        {
          "code": "3559096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.9547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 5MM ONB5STF",
      "code_information": [
        {
          "code": "3559097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 286,
          "minimum": 60.06,
          "maximum": 209.4092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 177.9978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3559115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 12FR 0200-12L",
      "code_information": [
        {
          "code": "3559117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 861.3601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM CDH29P",
      "code_information": [
        {
          "code": "3559120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2660,
          "minimum": 558.6,
          "maximum": 1947.652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1655.5042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3559142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2143,
          "minimum": 450.03,
          "maximum": 1569.1046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1333.7389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15MM XTHICK SIG60AXT",
      "code_information": [
        {
          "code": "3559150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1896,
          "minimum": 398.16,
          "maximum": 1388.2512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1180.0135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1065832",
      "code_information": [
        {
          "code": "3559158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.7542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIAMONDTOUCH IN9152",
      "code_information": [
        {
          "code": "3559159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 632,
          "minimum": 132.72,
          "maximum": 462.7504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 393.3378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN GUARD",
      "code_information": [
        {
          "code": "3559160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1683.5108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLLEVE-SPIN GUARD",
      "code_information": [
        {
          "code": "3559161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1702,
          "minimum": 357.42,
          "maximum": 1246.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1059.2737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYDROGEL EEG",
      "code_information": [
        {
          "code": "3559175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.2304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J493H",
      "code_information": [
        {
          "code": "3559178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0 1635G",
      "code_information": [
        {
          "code": "3559179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J670G",
      "code_information": [
        {
          "code": "3559180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP497G",
      "code_information": [
        {
          "code": "3559181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 185,
          "minimum": 38.85,
          "maximum": 135.457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 115.1384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPREADER-SILIPOS GEL TOE MED",
      "code_information": [
        {
          "code": "3559185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-12MM 10*/MD 08.815.242S",
      "code_information": [
        {
          "code": "3559197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 23165,
          "minimum": 4864.65,
          "maximum": 16961.413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 14417.201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW-ACC BONCH AF541",
      "code_information": [
        {
          "code": "3559228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW,STD BLUE AF541 73-112096",
      "code_information": [
        {
          "code": "3559229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM/MED/LG",
      "code_information": [
        {
          "code": "3559240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 189,
          "minimum": 39.69,
          "maximum": 138.3858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.6279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LAMINARIA-#4 MED 60MM 021004",
      "code_information": [
        {
          "code": "3559244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.2MM XS 45303125",
      "code_information": [
        {
          "code": "3559246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD 4033A",
      "code_information": [
        {
          "code": "3559253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X40MM 7005-3340",
      "code_information": [
        {
          "code": "3559254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X60MM 7005-3360",
      "code_information": [
        {
          "code": "3559255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 10G 0306-530-000",
      "code_information": [
        {
          "code": "3559260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 642,
          "minimum": 134.82,
          "maximum": 470.0724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 399.5615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ TRANS 0909-400-500",
      "code_information": [
        {
          "code": "3559261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 435.659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 1025-011-500",
      "code_information": [
        {
          "code": "3559262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2367,
          "minimum": 497.07,
          "maximum": 1733.1174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1473.1498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CEMENT 0306-410-000",
      "code_information": [
        {
          "code": "3559263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 604,
          "minimum": 126.84,
          "maximum": 442.2488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 375.9115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INDIGO SEP12",
      "code_information": [
        {
          "code": "3559264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8101,
          "minimum": 1701.21,
          "maximum": 5931.5522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5041.8194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURRETTE-10G 0306-621-000",
      "code_information": [
        {
          "code": "3559265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3257,
          "minimum": 683.97,
          "maximum": 2384.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2027.0591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FLEX CUFFED",
      "code_information": [
        {
          "code": "3559271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 750,
          "minimum": 157.5,
          "maximum": 549.15,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 466.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-FLEXIBLE 2.9MM 682.622",
      "code_information": [
        {
          "code": "3559276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1253.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2516H",
      "code_information": [
        {
          "code": "3559281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.7265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COILED 60\\\" CT 100113",
      "code_information": [
        {
          "code": "3559287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-GPS 3.5MM 6143.2572",
      "code_information": [
        {
          "code": "3559291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1879.5574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4.2X360/SM 1320-3642S",
      "code_information": [
        {
          "code": "3559293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 596.8528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383593",
      "code_information": [
        {
          "code": "3559297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.9502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON BLK 4-0   1854G",
      "code_information": [
        {
          "code": "3559366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 PC-1  1855G",
      "code_information": [
        {
          "code": "3559390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER 4MM SB4000SA",
      "code_information": [
        {
          "code": "3559391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1162,
          "minimum": 244.02,
          "maximum": 850.8164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 723.1939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING 19F L",
      "code_information": [
        {
          "code": "3559394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCESS 8MM",
      "code_information": [
        {
          "code": "3559395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 939,
          "minimum": 197.19,
          "maximum": 687.5358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 584.4054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3559401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1438,
          "minimum": 301.98,
          "maximum": 1052.9036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 894.9681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FIBERLASE CO2",
      "code_information": [
        {
          "code": "3559407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3159.7725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0/PC-3  1865G",
      "code_information": [
        {
          "code": "3559425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MIC J FEDDING 8200",
      "code_information": [
        {
          "code": "3559430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 861.3601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT SINGLE 5' RT219",
      "code_information": [
        {
          "code": "3559433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 377,
          "minimum": 79.17,
          "maximum": 276.0394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 234.6335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT DUAL HTDRT380",
      "code_information": [
        {
          "code": "3559434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 386,
          "minimum": 81.06,
          "maximum": 282.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 240.2348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 EPM8706",
      "code_information": [
        {
          "code": "3559435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 814,
          "minimum": 170.94,
          "maximum": 596.0108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 506.6092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT OPEN EB240",
      "code_information": [
        {
          "code": "3559437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1420.2483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 2X315MM 703561",
      "code_information": [
        {
          "code": "3559445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.9403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VIZISNOT2 19G",
      "code_information": [
        {
          "code": "3559447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2067,
          "minimum": 434.07,
          "maximum": 1513.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1286.4388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIP 8.5X110 72200436",
      "code_information": [
        {
          "code": "3559448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X56MM 03.130.202",
      "code_information": [
        {
          "code": "3559456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.100",
      "code_information": [
        {
          "code": "3559462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 K-WIRE",
      "code_information": [
        {
          "code": "3559463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 618.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 22X10MM 03.501.760",
      "code_information": [
        {
          "code": "3559485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2487,
          "minimum": 522.27,
          "maximum": 1820.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1547.8342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2590S",
      "code_information": [
        {
          "code": "3559495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 176.7531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2591S",
      "code_information": [
        {
          "code": "3559496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 176.7531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM GPS 6143.2580S",
      "code_information": [
        {
          "code": "3559499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1148.895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM GPS 6143.2582S",
      "code_information": [
        {
          "code": "3559500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1148.895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM GPS 6143.2584S",
      "code_information": [
        {
          "code": "3559501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1148.895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 8FR G00980",
      "code_information": [
        {
          "code": "3559527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-6MM BALT 110135",
      "code_information": [
        {
          "code": "3559542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 710,
          "minimum": 149.1,
          "maximum": 519.862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 441.8827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 116239",
      "code_information": [
        {
          "code": "3559543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1039,
          "minimum": 218.19,
          "maximum": 760.7558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 646.6424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-OVASSAPIAN 85MM BD6075",
      "code_information": [
        {
          "code": "3559545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/55 STANDARD 7607",
      "code_information": [
        {
          "code": "3559546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2974,
          "minimum": 624.54,
          "maximum": 2177.5628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1850.9284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8340050",
      "code_information": [
        {
          "code": "3559560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9498,
          "minimum": 1994.58,
          "maximum": 6954.4356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5911.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y3/8X3/16X3/16 10518",
      "code_information": [
        {
          "code": "3559582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CABLE 323.1090",
      "code_information": [
        {
          "code": "3559590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1886,
          "minimum": 396.06,
          "maximum": 1380.9292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1173.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BRAD POINT 4MM 323.010",
      "code_information": [
        {
          "code": "3559591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2034,
          "minimum": 427.14,
          "maximum": 1489.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1265.9006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRIPLE LUMEN 5.5FR",
      "code_information": [
        {
          "code": "3559593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1240,
          "minimum": 260.4,
          "maximum": 907.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 771.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL LUMEN 4FR",
      "code_information": [
        {
          "code": "3559594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1190,
          "minimum": 249.9,
          "maximum": 871.318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 740.6203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 4.5X15 9009-2001",
      "code_information": [
        {
          "code": "3559598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3360,
          "minimum": 705.6,
          "maximum": 2460.192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2091.1632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM XT SIGTRSB45AXT",
      "code_information": [
        {
          "code": "3559607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2514,
          "minimum": 527.94,
          "maximum": 1840.7508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1564.6382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/F P01-900-1902",
      "code_information": [
        {
          "code": "3559612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1683.5108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/M P01-900-1903",
      "code_information": [
        {
          "code": "3559613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1683.5108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEE-UTILIZATION PER CASE",
      "code_information": [
        {
          "code": "3559626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4344,
          "minimum": 912.24,
          "maximum": 3180.6768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2703.5753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV",
      "code_information": [
        {
          "code": "3559628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.0MM 705360",
      "code_information": [
        {
          "code": "3559634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1250,
          "minimum": 262.5,
          "maximum": 915.25,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 777.9625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SENSOR SPO2 1822A-25",
      "code_information": [
        {
          "code": "3559649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 80.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASO 12FR",
      "code_information": [
        {
          "code": "3559651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A435",
      "code_information": [
        {
          "code": "3559659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 244.5914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWRIST 2.5MM 60-25326",
      "code_information": [
        {
          "code": "3559663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.0754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #4 051114-10",
      "code_information": [
        {
          "code": "3559671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 150.6135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC",
      "code_information": [
        {
          "code": "3559672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 341,
          "minimum": 71.61,
          "maximum": 249.6802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 212.2282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 3.5X65",
      "code_information": [
        {
          "code": "3559673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1828,
          "minimum": 383.88,
          "maximum": 1338.4616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1137.6924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURETTE-0* TIP TDC005",
      "code_information": [
        {
          "code": "3559688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1357.389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-0* TIP NAVIGATION",
      "code_information": [
        {
          "code": "3559690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1232.2926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON SILK    C-021-",
      "code_information": [
        {
          "code": "3560079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.4884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PS-2/4-0   J496G",
      "code_information": [
        {
          "code": "3560474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J492G",
      "code_information": [
        {
          "code": "3560778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.6567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J493G",
      "code_information": [
        {
          "code": "3560802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J494G",
      "code_information": [
        {
          "code": "3560836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 4-0  J-496-H",
      "code_information": [
        {
          "code": "3560879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.7198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-497-G",
      "code_information": [
        {
          "code": "3560893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-774-D",
      "code_information": [
        {
          "code": "3561255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J762D",
      "code_information": [
        {
          "code": "3561415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0        699H",
      "code_information": [
        {
          "code": "3561696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y496G",
      "code_information": [
        {
          "code": "3562112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y494G",
      "code_information": [
        {
          "code": "3562131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS-2    1666",
      "code_information": [
        {
          "code": "3562141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 40,
          "minimum": 8.4,
          "maximum": 29.288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 24.8948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8619G",
      "code_information": [
        {
          "code": "3562217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8699G",
      "code_information": [
        {
          "code": "3562235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 53.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIVERSAL*****",
      "code_information": [
        {
          "code": "3566070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.6634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-EAR DAVOL 3 OZ 529****",
      "code_information": [
        {
          "code": "3566353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 32.3632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CT FAST LOAD DUAL",
      "code_information": [
        {
          "code": "3566355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.7187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-PACK DUAL EMPOWERCTA",
      "code_information": [
        {
          "code": "3566380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CRANIAL ACCESS  INSHITH",
      "code_information": [
        {
          "code": "3566755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2554,
          "minimum": 536.34,
          "maximum": 1870.0388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1589.533,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MULTI PODUS 9274-56XX",
      "code_information": [
        {
          "code": "3566785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 982,
          "minimum": 206.22,
          "maximum": 719.0204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 611.1673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NURSING SUPPLEMENTAL",
      "code_information": [
        {
          "code": "3566790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.3976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FECAL MANAGEMENT",
      "code_information": [
        {
          "code": "3566823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1240,
          "minimum": 260.4,
          "maximum": 907.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 771.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-REPLACEMENT FECAL MGMT",
      "code_information": [
        {
          "code": "3566824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3567605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 921,
          "minimum": 193.41,
          "maximum": 674.3562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 573.2028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "THERMOSET-INJECTATE    4142403",
      "code_information": [
        {
          "code": "3568123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 8.0MM",
      "code_information": [
        {
          "code": "3568561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.9547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 6.0MM",
      "code_information": [
        {
          "code": "3568562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 450,
          "minimum": 94.5,
          "maximum": 329.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 280.0665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3568563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.9547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 508,
          "minimum": 106.68,
          "maximum": 371.9576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 316.164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU UNCUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4259105",
      "code_information": [
        {
          "code": "3568757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 380,
          "minimum": 79.8,
          "maximum": 278.236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 236.5006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-NEONATAL   42634-05",
      "code_information": [
        {
          "code": "3568760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXISENSOR-PEDIATRIC D20",
      "code_information": [
        {
          "code": "3568762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 136.299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565200",
      "code_information": [
        {
          "code": "3569240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 705.1452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565150",
      "code_information": [
        {
          "code": "3569242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 705.1452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16 FR",
      "code_information": [
        {
          "code": "3569250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 366,
          "minimum": 76.86,
          "maximum": 267.9852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 227.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18 FR",
      "code_information": [
        {
          "code": "3569252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 366,
          "minimum": 76.86,
          "maximum": 267.9852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 227.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH URETHRAL BARD 772415",
      "code_information": [
        {
          "code": "3569258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20,
          "minimum": 4.2,
          "maximum": 14.644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 12.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-ESOPH TRACH     5-18541",
      "code_information": [
        {
          "code": "3569601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1095,
          "minimum": 229.95,
          "maximum": 801.759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 681.4951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY CATH/DRN BAG 6176LL",
      "code_information": [
        {
          "code": "3569779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR   6146LL",
      "code_information": [
        {
          "code": "3569805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/ BAG 18FR  6148LL",
      "code_information": [
        {
          "code": "3569853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 66.5936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG LTX 16F 6165L",
      "code_information": [
        {
          "code": "3569870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LOOP CCL DYNJ50892",
      "code_information": [
        {
          "code": "3570230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 189.2005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMBAR PUNCTURE ADT 4301C",
      "code_information": [
        {
          "code": "3570322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMB PUNC PED   4304C****",
      "code_information": [
        {
          "code": "3570330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR PROC OP DYNJ31942F",
      "code_information": [
        {
          "code": "3570410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 558,
          "minimum": 117.18,
          "maximum": 408.5676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.2825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PARA/PUD PHARMASEAL 4540A",
      "code_information": [
        {
          "code": "3570603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.8173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 6.0F",
      "code_information": [
        {
          "code": "3570605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.9436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 8.3F",
      "code_information": [
        {
          "code": "3570610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1211,
          "minimum": 254.31,
          "maximum": 886.6942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 753.6901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SINGLE TAP BLOCK SPEC015",
      "code_information": [
        {
          "code": "3570640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 687,
          "minimum": 144.27,
          "maximum": 503.0214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 427.5682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-NICU UMBILICAL CATH",
      "code_information": [
        {
          "code": "3570745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 543,
          "minimum": 114.03,
          "maximum": 397.5846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 337.9469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-DRESSING CHANGE 4D",
      "code_information": [
        {
          "code": "3571200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 114.5161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-THORACENTESIS CURITY 5014*",
      "code_information": [
        {
          "code": "3571304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 175.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 16FR 0100-16LV",
      "code_information": [
        {
          "code": "3571985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.2559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING W/ST 10F 43\\\"",
      "code_information": [
        {
          "code": "3571990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.3345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 8.0     86552",
      "code_information": [
        {
          "code": "3572176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 6LPC",
      "code_information": [
        {
          "code": "3572189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 743,
          "minimum": 156.03,
          "maximum": 544.0246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 462.4209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 6CFS",
      "code_information": [
        {
          "code": "3572191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 6MM",
      "code_information": [
        {
          "code": "3572195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 507,
          "minimum": 106.47,
          "maximum": 371.2254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 315.5416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRP MIC-KEY 14FR 1.5CM",
      "code_information": [
        {
          "code": "3572305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 626.7266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 35FR     125135",
      "code_information": [
        {
          "code": "3572307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.9248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 39FR     125139",
      "code_information": [
        {
          "code": "3572309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.9248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 41FR     125141",
      "code_information": [
        {
          "code": "3572311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.9248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 37FR LFT 125037",
      "code_information": [
        {
          "code": "3572315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 619,
          "minimum": 129.99,
          "maximum": 453.2318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 385.247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BLAKEMORE 20 FR      9210",
      "code_information": [
        {
          "code": "3572344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2672,
          "minimum": 561.12,
          "maximum": 1956.4384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1662.9726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 5F 20\\\"     461412",
      "code_information": [
        {
          "code": "3572425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 6.5F 36\\\"   461438",
      "code_information": [
        {
          "code": "3572430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASOGASTRIC 8FR",
      "code_information": [
        {
          "code": "3572485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 18FR 20CC",
      "code_information": [
        {
          "code": "3572530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 237,
          "minimum": 49.77,
          "maximum": 173.5314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 147.5017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.5       86215",
      "code_information": [
        {
          "code": "3572860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.0       8621",
      "code_information": [
        {
          "code": "3572863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.0       86212",
      "code_information": [
        {
          "code": "3572865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.5       86213",
      "code_information": [
        {
          "code": "3572866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 8.0C      86216",
      "code_information": [
        {
          "code": "3572867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "3573037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "3573039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM",
      "code_information": [
        {
          "code": "3573355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 440.0156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 8MM",
      "code_information": [
        {
          "code": "3573357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 440.0156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF    SZs  DCTs",
      "code_information": [
        {
          "code": "3573530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 461,
          "minimum": 96.81,
          "maximum": 337.5442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 286.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FENESTRATED SZ 4TO10  CFN",
      "code_information": [
        {
          "code": "3573565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 213.4729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH #6   518035",
      "code_information": [
        {
          "code": "3573650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1816.0757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 8FR     8LPC",
      "code_information": [
        {
          "code": "3573714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 743,
          "minimum": 156.03,
          "maximum": 544.0246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 462.4209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,TRAC REINFO 6.0 86548",
      "code_information": [
        {
          "code": "3573730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 7.0     86550",
      "code_information": [
        {
          "code": "3573735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEEY PED",
      "code_information": [
        {
          "code": "3573845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 427,
          "minimum": 89.67,
          "maximum": 312.6494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 583,
          "minimum": 122.43,
          "maximum": 426.8726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 362.8417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 520,
          "minimum": 109.2,
          "maximum": 380.744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 323.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 0.8MM",
      "code_information": [
        {
          "code": "3573906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 311.8074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3573910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 435,
          "minimum": 91.35,
          "maximum": 318.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 270.731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF BLU 10.0MM",
      "code_information": [
        {
          "code": "3573911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 6.0MM",
      "code_information": [
        {
          "code": "3573914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 6.0MM",
      "code_information": [
        {
          "code": "3573915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1400,
          "minimum": 294,
          "maximum": 1025.08,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 871.318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 8.0MM",
      "code_information": [
        {
          "code": "3573916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 700.1662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF 7.0MM",
      "code_information": [
        {
          "code": "3573920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 60A160",
      "code_information": [
        {
          "code": "3573926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 672,
          "minimum": 141.12,
          "maximum": 492.0384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 418.2326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 7MM",
      "code_information": [
        {
          "code": "3573937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE XL 7",
      "code_information": [
        {
          "code": "3573950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 700.1662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNDERPAD-CGLIDE XL 40X80 PK",
      "code_information": [
        {
          "code": "3574527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-D&C COLLECTION 23116",
      "code_information": [
        {
          "code": "3574563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 77.7963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-MITY-ONE MYSTIC   10058",
      "code_information": [
        {
          "code": "3574642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 661,
          "minimum": 138.81,
          "maximum": 483.9842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 411.3866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI-REFLUX",
      "code_information": [
        {
          "code": "3574651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING TRACH    PMV007",
      "code_information": [
        {
          "code": "3574654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 879,
          "minimum": 184.59,
          "maximum": 643.6038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 547.0632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAX-BONE                  W31G",
      "code_information": [
        {
          "code": "3575105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER PK",
      "code_information": [
        {
          "code": "3575110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 170.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER XLPK",
      "code_information": [
        {
          "code": "3575115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 414,
          "minimum": 86.94,
          "maximum": 303.1308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.6612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-FOAM POSITIONING DISP",
      "code_information": [
        {
          "code": "3575122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MEDTRONIC ATRIAL    6492F",
      "code_information": [
        {
          "code": "3575572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.6479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK L/XL",
      "code_information": [
        {
          "code": "3575890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-THROMBIDISC TOPICAL HEMO",
      "code_information": [
        {
          "code": "3575891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.5715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD S/M",
      "code_information": [
        {
          "code": "3575892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 258.2835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD L/XL",
      "code_information": [
        {
          "code": "3575893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 518,
          "minimum": 108.78,
          "maximum": 379.2796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 322.3877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-LEG POSITIONER 111618",
      "code_information": [
        {
          "code": "3575894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 213.4729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK S/M",
      "code_information": [
        {
          "code": "3575895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRISTLET-PORTHOLE 6600021150",
      "code_information": [
        {
          "code": "3576870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 34.2304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH 442-2",
      "code_information": [
        {
          "code": "3576880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EXUDE HYDRO 6X6",
      "code_information": [
        {
          "code": "3580000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-OPTICELL AG+4X5",
      "code_information": [
        {
          "code": "3580001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.2647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 16FR",
      "code_information": [
        {
          "code": "3580005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST RT XS 8",
      "code_information": [
        {
          "code": "3580008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.9779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LT XS 8",
      "code_information": [
        {
          "code": "3580009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 EASY CAP II",
      "code_information": [
        {
          "code": "3580015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 171,
          "minimum": 35.91,
          "maximum": 125.2062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 106.4253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 14FR",
      "code_information": [
        {
          "code": "3580016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-NASAL L/R STANDARD",
      "code_information": [
        {
          "code": "3580017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 262,
          "minimum": 55.02,
          "maximum": 191.8364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 163.0609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT MED CLOSED",
      "code_information": [
        {
          "code": "3580023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.6634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,OVAL 5.5X13CM AR-8550COE",
      "code_information": [
        {
          "code": "3580025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 282.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3590000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1467,
          "minimum": 308.07,
          "maximum": 1074.1374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 913.0168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTROSTOMY 18FR   100-18",
      "code_information": [
        {
          "code": "3590008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.2559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY BASIC         4380",
      "code_information": [
        {
          "code": "3590013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 301,
          "minimum": 63.21,
          "maximum": 220.3922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.3334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSAL 10FR  15642-001",
      "code_information": [
        {
          "code": "3590100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REPAIR ASH CATH      RPK01",
      "code_information": [
        {
          "code": "3590134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 693,
          "minimum": 145.53,
          "maximum": 507.4146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 431.3024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.6756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LMH LMH-1001",
      "code_information": [
        {
          "code": "3598009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1671.0634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 03.130.302",
      "code_information": [
        {
          "code": "3598013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-BLUE RHINO G2",
      "code_information": [
        {
          "code": "3598017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1775.6216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-STERLING 3.0X60X150",
      "code_information": [
        {
          "code": "3598023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1841,
          "minimum": 386.61,
          "maximum": 1347.9802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1145.7832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORGANIZER-7 DAY PILL 70069L",
      "code_information": [
        {
          "code": "3598024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.6777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I-KNIFE II 8065921502",
      "code_information": [
        {
          "code": "3598025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.3765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARDS-NEONATAL NOISE NON-MAG",
      "code_information": [
        {
          "code": "3598028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 215,
          "minimum": 45.15,
          "maximum": 157.423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.8096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE RCM-14815",
      "code_information": [
        {
          "code": "3598048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 839,
          "minimum": 176.19,
          "maximum": 614.3158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 522.1684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPEN KNEE ABS-2001-OT",
      "code_information": [
        {
          "code": "3598069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2984.2641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE GEL",
      "code_information": [
        {
          "code": "3598076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 155.5925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACEMENT GEL",
      "code_information": [
        {
          "code": "3598077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER GEL",
      "code_information": [
        {
          "code": "3598078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 155.5925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-SAMPLE EXTENSION 1841-25",
      "code_information": [
        {
          "code": "3598081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.2924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-8MM ENT TUBE NVM5 2010480",
      "code_information": [
        {
          "code": "3598086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.6049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-MEGADYNE 10FT SMOKE",
      "code_information": [
        {
          "code": "3598109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 145.0122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MEGADYNE F/SMOKE",
      "code_information": [
        {
          "code": "3598110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ZIP PEN F/SMOKE EVAC",
      "code_information": [
        {
          "code": "3598111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 220.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER SO SPECTRUM SU",
      "code_information": [
        {
          "code": "3598112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.9048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER S1 SPECTRUM SU",
      "code_information": [
        {
          "code": "3598113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.9048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1603G",
      "code_information": [
        {
          "code": "3598114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 1661G",
      "code_information": [
        {
          "code": "3598115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MINIVAC MGVSFT10",
      "code_information": [
        {
          "code": "3598117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.8871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHTMAT-ULTRATHIN UA2550",
      "code_information": [
        {
          "code": "3598118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 818,
          "minimum": 171.78,
          "maximum": 598.9396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 509.0987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MEGADYN SPECULUM 23951",
      "code_information": [
        {
          "code": "3598134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.7187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-221C-0427",
      "code_information": [
        {
          "code": "3598154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 495.4065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLIDE-OCULAR KDB GLIDE",
      "code_information": [
        {
          "code": "3598156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROVU DISP PHB-03",
      "code_information": [
        {
          "code": "3598158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11119,
          "minimum": 2334.99,
          "maximum": 8141.3318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6920.132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BLUGRIGGS PERC DILATION",
      "code_information": [
        {
          "code": "3598159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2213,
          "minimum": 464.73,
          "maximum": 1620.3586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1377.3048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5X10 AR-8610TDC-01C",
      "code_information": [
        {
          "code": "3598172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1461.9471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-EGG 4.0MM 5820-015-040",
      "code_information": [
        {
          "code": "3598178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 2.0 6007-1200",
      "code_information": [
        {
          "code": "3598184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 604.3213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY SZ 8 8DCFS",
      "code_information": [
        {
          "code": "3598187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBT 7MM EMG ET 2010470",
      "code_information": [
        {
          "code": "3598201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1424.6049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LAPIPLASTY 40X11 SM-4011",
      "code_information": [
        {
          "code": "3598213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-MULTIPURPOSE TUBING",
      "code_information": [
        {
          "code": "3598219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-REINFUSION SB1E",
      "code_information": [
        {
          "code": "3598227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 193.5571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 3.2 HAMMER 702632",
      "code_information": [
        {
          "code": "3598233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4242,
          "minimum": 890.82,
          "maximum": 3105.9924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2640.0935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK DS AR-8991DS",
      "code_information": [
        {
          "code": "3598238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1938,
          "minimum": 406.98,
          "maximum": 1419.0036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1206.1531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 PLUS VCP317H",
      "code_information": [
        {
          "code": "3598242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6.2237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM CSS-072-37-SQ",
      "code_information": [
        {
          "code": "3598257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 903.0589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-Z-FLO FLUID",
      "code_information": [
        {
          "code": "3598273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 441,
          "minimum": 92.61,
          "maximum": 322.9002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 274.4652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-25 G00896",
      "code_information": [
        {
          "code": "3598279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 193,
          "minimum": 40.53,
          "maximum": 141.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.1174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HIGH TORQUE 70-2001",
      "code_information": [
        {
          "code": "3598282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1378,
          "minimum": 289.38,
          "maximum": 1008.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 857.6259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP523H",
      "code_information": [
        {
          "code": "3598283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.0764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.3MM AR-7535",
      "code_information": [
        {
          "code": "3598289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 464.9104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYNGECTOMY SZ10 6132",
      "code_information": [
        {
          "code": "3598291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2343,
          "minimum": 492.03,
          "maximum": 1715.5446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1458.2129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-PREFILL AREOSOL 500M",
      "code_information": [
        {
          "code": "3598292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUNCTURE 17FR/10MM 8141US",
      "code_information": [
        {
          "code": "3598296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2695,
          "minimum": 565.95,
          "maximum": 1973.279,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1677.2871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORCAPOD SUCTION BIOPSY",
      "code_information": [
        {
          "code": "3598300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.2016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-E-Z CLEAN 0016AM",
      "code_information": [
        {
          "code": "3598301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.6567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 22GX.75\\\"",
      "code_information": [
        {
          "code": "3598320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL 80M 04.038.380S",
      "code_information": [
        {
          "code": "3598333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4478,
          "minimum": 940.38,
          "maximum": 3278.7916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2786.9729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153204",
      "code_information": [
        {
          "code": "3598338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 SURGILON 8886195151",
      "code_information": [
        {
          "code": "3598362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.7198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 SURGILON 8886195141",
      "code_information": [
        {
          "code": "3598363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUB LIPO 3-TT-FILTRON",
      "code_information": [
        {
          "code": "3598384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2403,
          "minimum": 504.63,
          "maximum": 1759.4766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1495.5551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHEST-DRAIN 4050-100N",
      "code_information": [
        {
          "code": "3598393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.8705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEO TEE 1050810",
      "code_information": [
        {
          "code": "3598397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 179.2426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION SZ:8",
      "code_information": [
        {
          "code": "3598398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 213.4729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 10.5 CLR",
      "code_information": [
        {
          "code": "3598403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY L-WIRE 20115",
      "code_information": [
        {
          "code": "3598404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 362,
          "minimum": 76.02,
          "maximum": 265.0564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.2979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-LIGATING SURGITIE SGL-1",
      "code_information": [
        {
          "code": "3598405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 621,
          "minimum": 130.41,
          "maximum": 454.6962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 386.4918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 11 96\\\" Z880G",
      "code_information": [
        {
          "code": "3598407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-POWER 45MM FLEX PSEE45",
      "code_information": [
        {
          "code": "3598408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2062,
          "minimum": 433.02,
          "maximum": 1509.7964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1283.3269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 32FR 056132",
      "code_information": [
        {
          "code": "3598409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SOFSIK 2-0 18\\\" GS63M",
      "code_information": [
        {
          "code": "3598410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.9004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOSOF 5-0 SN-661",
      "code_information": [
        {
          "code": "3598412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1 G48",
      "code_information": [
        {
          "code": "3598413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 91.4884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0 3844G",
      "code_information": [
        {
          "code": "3598415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.8871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 714G",
      "code_information": [
        {
          "code": "3598417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD WARMING RAPID 24355",
      "code_information": [
        {
          "code": "3598418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 275.0875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTOLOGY 2.3MMX240CM",
      "code_information": [
        {
          "code": "3598419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 150.6135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY LONG 2.4MM E1450-6",
      "code_information": [
        {
          "code": "3598420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.7542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y527H",
      "code_information": [
        {
          "code": "3598424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-GRAVITY SPIKE FLUID MGMT",
      "code_information": [
        {
          "code": "3598425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEM SILVER 6.5X7",
      "code_information": [
        {
          "code": "3598426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 142.5227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 20FR 5CC",
      "code_information": [
        {
          "code": "3598427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.7542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-J-TIP .035X145CM",
      "code_information": [
        {
          "code": "3598428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 205.3821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 30CC 16FR",
      "code_information": [
        {
          "code": "3598429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2 490T",
      "code_information": [
        {
          "code": "3598434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII BLADED CTB33",
      "code_information": [
        {
          "code": "3598436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM BLADELESS CTR03",
      "code_information": [
        {
          "code": "3598437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND 10FR DYNJWE1321A",
      "code_information": [
        {
          "code": "3598439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ULNAR NERVE 79-91100",
      "code_information": [
        {
          "code": "3598441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 40.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POWDER-HEMOSTAT AVITENE 1 GRAM",
      "code_information": [
        {
          "code": "3598442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1703,
          "minimum": 357.63,
          "maximum": 1246.9366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1059.8961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RADIAL ARTERY 20GX1.75\\\"",
      "code_information": [
        {
          "code": "3598444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 265,
          "minimum": 55.65,
          "maximum": 194.033,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 164.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL RHINO ROCKET LRG",
      "code_information": [
        {
          "code": "3598446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-FOREIGN BODY 60613",
      "code_information": [
        {
          "code": "3598447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 663,
          "minimum": 139.23,
          "maximum": 485.4486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 412.6313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 24FR 056124",
      "code_information": [
        {
          "code": "3598448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-HYDROFERA 6X6 HB6614",
      "code_information": [
        {
          "code": "3598449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.6767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SMALL WIDE",
      "code_information": [
        {
          "code": "3598450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 136.299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARYNGECTOMY SZ6 6LGT",
      "code_information": [
        {
          "code": "3598451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 457,
          "minimum": 95.97,
          "maximum": 334.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 284.4231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X285MM 703586",
      "code_information": [
        {
          "code": "3598458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 352.2614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 352.2614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 18FR",
      "code_information": [
        {
          "code": "3598463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 609.9226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 700.1662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATFORM-GELPOINT PATH CNB11",
      "code_information": [
        {
          "code": "3598471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3072.0183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VINYL CONNECTING G02791",
      "code_information": [
        {
          "code": "3598473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 143.7675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRUIT, CROSS VENT 80011",
      "code_information": [
        {
          "code": "3598474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 323,
          "minimum": 67.83,
          "maximum": 236.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 201.0255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR, NEO W/MASK",
      "code_information": [
        {
          "code": "3598475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 342,
          "minimum": 71.82,
          "maximum": 250.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 212.8505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3598478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 484.8262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC #1 48G",
      "code_information": [
        {
          "code": "3598479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.6634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STEM 222-496100",
      "code_information": [
        {
          "code": "3598480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5912,
          "minimum": 1241.52,
          "maximum": 4328.7664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3679.4514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRIP-PLATINUM MS04R-IP10X-0JH",
      "code_information": [
        {
          "code": "3598481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4118,
          "minimum": 864.78,
          "maximum": 3015.1996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2562.9197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-ENDOCAPSULE 10 MAJ2027",
      "code_information": [
        {
          "code": "3598483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3003,
          "minimum": 630.63,
          "maximum": 2198.7966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1868.9771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-10G/7.75\\\" 0306-810-000",
      "code_information": [
        {
          "code": "3598484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 724,
          "minimum": 152.04,
          "maximum": 530.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 450.5959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77420",
      "code_information": [
        {
          "code": "3598485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 584,
          "minimum": 122.64,
          "maximum": 427.6048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 363.4641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/SUPPORT #6",
      "code_information": [
        {
          "code": "3598487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 784,
          "minimum": 164.64,
          "maximum": 574.0448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 487.9381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST 4050-100N",
      "code_information": [
        {
          "code": "3598488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 439.3932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-GONIOTOMY TRABEX 600042",
      "code_information": [
        {
          "code": "3598489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3014,
          "minimum": 632.94,
          "maximum": 2206.8508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1875.8232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-STRAIGHT JAW NSLX137S",
      "code_information": [
        {
          "code": "3598493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2542,
          "minimum": 533.82,
          "maximum": 1861.2524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1582.0645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW NSLX137C",
      "code_information": [
        {
          "code": "3598494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2637,
          "minimum": 553.77,
          "maximum": 1930.8114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1641.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW 25CM NSLX125C",
      "code_information": [
        {
          "code": "3598495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2676,
          "minimum": 561.96,
          "maximum": 1959.3672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1665.4621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JADA POSTPARTUM",
      "code_information": [
        {
          "code": "3598497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5844,
          "minimum": 1227.24,
          "maximum": 4278.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3637.1303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA G PROCEDURAL PUG",
      "code_information": [
        {
          "code": "3598498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9014,
          "minimum": 1892.94,
          "maximum": 6600.0508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5610.0432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-4MM/SHORT 1149.8052",
      "code_information": [
        {
          "code": "3598502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1587.6659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN",
      "code_information": [
        {
          "code": "3598508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN",
      "code_information": [
        {
          "code": "3598509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1055,
          "minimum": 221.55,
          "maximum": 772.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 656.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94975",
      "code_information": [
        {
          "code": "3598515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1030,
          "minimum": 216.3,
          "maximum": 754.166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 641.0411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYN W/EL SZ10 6136",
      "code_information": [
        {
          "code": "3598520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4004,
          "minimum": 840.84,
          "maximum": 2931.7288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2491.9695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.4X100/LG AGK10100",
      "code_information": [
        {
          "code": "3598521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 275.0875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X120MM 45302001",
      "code_information": [
        {
          "code": "3598524",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 245.2138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNIT-TI-KNOT QUICK LOAD 030510",
      "code_information": [
        {
          "code": "3598527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PICO 14 WOUND 15X30CM",
      "code_information": [
        {
          "code": "3598530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1724,
          "minimum": 362.04,
          "maximum": 1262.3128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1072.9659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1590,
          "minimum": 333.9,
          "maximum": 1164.198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 989.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY STANDARD 7607",
      "code_information": [
        {
          "code": "3598534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1347,
          "minimum": 282.87,
          "maximum": 986.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 838.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND XTRASORB 6X9",
      "code_information": [
        {
          "code": "3598535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1828,
          "minimum": 383.88,
          "maximum": 1338.4616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1137.6924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS SELECT",
      "code_information": [
        {
          "code": "3598538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY",
      "code_information": [
        {
          "code": "3598539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1496,
          "minimum": 314.16,
          "maximum": 1095.3712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 931.0655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LK/MD 3.1X328 705077",
      "code_information": [
        {
          "code": "3598547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1526,
          "minimum": 320.46,
          "maximum": 1117.3372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 949.7366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E-CATH PLUS 251285-41E",
      "code_information": [
        {
          "code": "3598551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-OVAL CUP BIOPSY SINGLE",
      "code_information": [
        {
          "code": "3598561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 364.0865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEATED W/GAS FILTER",
      "code_information": [
        {
          "code": "3598562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 652,
          "minimum": 136.92,
          "maximum": 477.3944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 405.7852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-10X360/RT/130* 3430-0360S",
      "code_information": [
        {
          "code": "3598565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6277,
          "minimum": 1318.17,
          "maximum": 4596.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3906.6165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3598587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X65MM 03.130.201",
      "code_information": [
        {
          "code": "3598592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1114,
          "minimum": 233.94,
          "maximum": 815.6708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 693.3202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-AIRSEAL CANN 8MM IAS8-DV",
      "code_information": [
        {
          "code": "3598593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 698.9215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTERD FURCATED ASM-EVAC",
      "code_information": [
        {
          "code": "3598594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 698.9215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS + MAP152",
      "code_information": [
        {
          "code": "3598601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.7187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRIVE T6 VARIAX2 705132",
      "code_information": [
        {
          "code": "3598602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2210,
          "minimum": 464.1,
          "maximum": 1618.162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1375.4377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREW T7 AO 45-27015",
      "code_information": [
        {
          "code": "3598609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1540,
          "minimum": 323.4,
          "maximum": 1127.588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 958.4498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROXIMATE PROCEDURE PPH03",
      "code_information": [
        {
          "code": "3598617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2668,
          "minimum": 560.28,
          "maximum": 1953.5096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1660.4832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X7MM 60-16007",
      "code_information": [
        {
          "code": "3598624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1349,
          "minimum": 283.29,
          "maximum": 987.7378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 839.5771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.9X115/35MM 92-19135",
      "code_information": [
        {
          "code": "3598625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2047,
          "minimum": 429.87,
          "maximum": 1498.8134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1273.9914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 163.6833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-EDIPURAL 17GX3.5 BUPIV",
      "code_information": [
        {
          "code": "3598647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 362,
          "minimum": 76.02,
          "maximum": 265.0564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.2979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 0.3MM DWD055",
      "code_information": [
        {
          "code": "3598653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1389,
          "minimum": 291.69,
          "maximum": 1017.0258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 864.4719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #2",
      "code_information": [
        {
          "code": "3598662",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDICLE ACCESS 624.027S",
      "code_information": [
        {
          "code": "3598668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2808.7558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISTAL DUODENOVIDEOSCOPE",
      "code_information": [
        {
          "code": "3598674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3598678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 974,
          "minimum": 204.54,
          "maximum": 713.1628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 606.1884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 24FR 77424",
      "code_information": [
        {
          "code": "3598679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 486,
          "minimum": 102.06,
          "maximum": 355.8492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 302.4718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X13MM AR-300-B001",
      "code_information": [
        {
          "code": "3598688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2343,
          "minimum": 492.03,
          "maximum": 1715.5446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1458.2129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X19.5MM AR-300-B201",
      "code_information": [
        {
          "code": "3598689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2396,
          "minimum": 503.16,
          "maximum": 1754.3512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1491.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8710H",
      "code_information": [
        {
          "code": "3598695",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.2846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8725H",
      "code_information": [
        {
          "code": "3598696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 385,
          "minimum": 80.85,
          "maximum": 281.897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 239.6124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8806H",
      "code_information": [
        {
          "code": "3598697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8718H",
      "code_information": [
        {
          "code": "3598698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 160.5715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8714H",
      "code_information": [
        {
          "code": "3598699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 215,
          "minimum": 45.15,
          "maximum": 157.423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.8096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W SPPRT MXPRSK05",
      "code_information": [
        {
          "code": "3598700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-BENSTON 260CM/.035\\\"",
      "code_information": [
        {
          "code": "3598702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 131.9424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/ SUPPORT #3",
      "code_information": [
        {
          "code": "3598704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 515.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-LT 130°/10X420 3530-0420S",
      "code_information": [
        {
          "code": "3598705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6277,
          "minimum": 1318.17,
          "maximum": 4596.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3906.6165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-XI 45MM 480445",
      "code_information": [
        {
          "code": "3598714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3242,
          "minimum": 680.82,
          "maximum": 2373.7924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2017.7235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-MUSTANG 7.0X20X135CM",
      "code_information": [
        {
          "code": "3598729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT,ACTIVE ANKLE HEEL-LOCK",
      "code_information": [
        {
          "code": "3598758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 464,
          "minimum": 97.44,
          "maximum": 339.7408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 288.7797,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Suture-7-0 Prolene Blue 8704H",
      "code_information": [
        {
          "code": "3598759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.6623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR,SURGICEL 3123SPEA",
      "code_information": [
        {
          "code": "3598761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 200.4031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP ESREC",
      "code_information": [
        {
          "code": "3598782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 3.0X2.1 45-30005",
      "code_information": [
        {
          "code": "3598799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1849,
          "minimum": 388.29,
          "maximum": 1353.8378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1150.7621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAC 425840405",
      "code_information": [
        {
          "code": "3598801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.67,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-8737-37",
      "code_information": [
        {
          "code": "3598812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE,.045\\\" THD AR-8737-05",
      "code_information": [
        {
          "code": "3598815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO 2.0MM DC6106",
      "code_information": [
        {
          "code": "3598843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1086.0357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.5X150MM 58862515",
      "code_information": [
        {
          "code": "3598844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM DSDS1011",
      "code_information": [
        {
          "code": "3598845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.5MM DSDS0025",
      "code_information": [
        {
          "code": "3598846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1186.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.0MM DSDS0030",
      "code_information": [
        {
          "code": "3598853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1186.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR SHEEHY 510-131C",
      "code_information": [
        {
          "code": "3598870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 127.5858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR PAPERELLA 510-043C",
      "code_information": [
        {
          "code": "3598871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 136.9214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F X-FIT 60-80323",
      "code_information": [
        {
          "code": "3598874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 903.0589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F 1.7MM 60-80317",
      "code_information": [
        {
          "code": "3598875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 903.0589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EAR-SPEEDIWICK 15MM OT-5201-50",
      "code_information": [
        {
          "code": "3598882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 15CM APYX-15-TP",
      "code_information": [
        {
          "code": "3598955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3007,
          "minimum": 631.47,
          "maximum": 2201.7254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1871.4666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERIOTOMY",
      "code_information": [
        {
          "code": "3598957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 549.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/46-62\\\" 1143PP",
      "code_information": [
        {
          "code": "3598975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 71.5725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 6.0 BIPOLAR",
      "code_information": [
        {
          "code": "3598997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2604,
          "minimum": 546.84,
          "maximum": 1906.6488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1620.6515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 004025",
      "code_information": [
        {
          "code": "3599029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-WIGGLE OPTIFLOW JR 2 M",
      "code_information": [
        {
          "code": "3599030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND HANZ RT LG",
      "code_information": [
        {
          "code": "3599041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 494,
          "minimum": 103.74,
          "maximum": 361.7068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 307.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.65MM MD 45303065",
      "code_information": [
        {
          "code": "3599049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.55MM MD 45303055",
      "code_information": [
        {
          "code": "3599050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8305H",
      "code_information": [
        {
          "code": "3599073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 141.278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-S-CURVE URETH DIL G32789",
      "code_information": [
        {
          "code": "3599074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2036,
          "minimum": 427.56,
          "maximum": 1490.7592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1267.1453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5x57MM 03.130.211",
      "code_information": [
        {
          "code": "3599095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
      "code_information": [
        {
          "code": "3599096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3493.3628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002352",
      "code_information": [
        {
          "code": "3599098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2262,
          "minimum": 475.02,
          "maximum": 1656.2364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1407.8009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002351",
      "code_information": [
        {
          "code": "3599099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2262,
          "minimum": 475.02,
          "maximum": 1656.2364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1407.8009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-BEADED 3MM 4150004030",
      "code_information": [
        {
          "code": "3599100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1211.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LONG ENCOMPASS JAW OLH",
      "code_information": [
        {
          "code": "3599110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 22744,
          "minimum": 4776.24,
          "maximum": 16653.1568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 14155.1833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
      "code_information": [
        {
          "code": "3599114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4881,
          "minimum": 1025.01,
          "maximum": 3573.8682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3037.788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-270-330C ALLOX-FH12SE",
      "code_information": [
        {
          "code": "3599115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6475,
          "minimum": 1359.75,
          "maximum": 4740.995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4029.8457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.3MM CSS-040-23",
      "code_information": [
        {
          "code": "3599133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 204.7597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-NAIL 3MM 4150004025",
      "code_information": [
        {
          "code": "3599135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1211.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-FULL VIP1137430",
      "code_information": [
        {
          "code": "3599140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FILL VIP1137431",
      "code_information": [
        {
          "code": "3599141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 176.7531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #4",
      "code_information": [
        {
          "code": "3599144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 870,
          "minimum": 182.7,
          "maximum": 637.014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 541.4619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-HINGED KNEE LG 11-0672-4",
      "code_information": [
        {
          "code": "3599145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 872,
          "minimum": 183.12,
          "maximum": 638.4784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 542.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-PROCESSOR DEPTH Z179994",
      "code_information": [
        {
          "code": "3599155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2423,
          "minimum": 508.83,
          "maximum": 1774.1206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1508.0025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X230/200MM 315.93",
      "code_information": [
        {
          "code": "3599157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1826,
          "minimum": 383.46,
          "maximum": 1336.9972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1136.4476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TENSIONER-CERCLAGE AR-7820",
      "code_information": [
        {
          "code": "3599172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2030,
          "minimum": 426.3,
          "maximum": 1486.366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1263.4111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CERCLAGE STR/LG AR-7822",
      "code_information": [
        {
          "code": "3599173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1033.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-INS MID/HINDFOOT FFSP1530",
      "code_information": [
        {
          "code": "3599178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1566.5053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LP PRP LEUKOCYTE POOR PRS6",
      "code_information": [
        {
          "code": "3599190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3723,
          "minimum": 781.83,
          "maximum": 2725.9806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2317.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-4160-40",
      "code_information": [
        {
          "code": "3599227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SET RENOVARP GIS-30",
      "code_information": [
        {
          "code": "3599230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/135X45 03.133.102",
      "code_information": [
        {
          "code": "3599237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1522,
          "minimum": 319.62,
          "maximum": 1114.4084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 947.2471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-100.783+/3H 954-0035",
      "code_information": [
        {
          "code": "3599249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1448,
          "minimum": 304.08,
          "maximum": 1060.2256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 901.1918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PARACENTESIS GIS-31",
      "code_information": [
        {
          "code": "3599291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 585.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MALE EXT PWM-030 PUREWICK",
      "code_information": [
        {
          "code": "3599292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.1241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 2 1/2\\\"",
      "code_information": [
        {
          "code": "3599298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 3\\\"",
      "code_information": [
        {
          "code": "3599299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-PLANTAR KERATOSIS WOMENS",
      "code_information": [
        {
          "code": "3599300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" SMALL",
      "code_information": [
        {
          "code": "3599306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" MEDIUM",
      "code_information": [
        {
          "code": "3599307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" LARGE",
      "code_information": [
        {
          "code": "3599308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE DOUBLE",
      "code_information": [
        {
          "code": "3599309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE SINGLE",
      "code_information": [
        {
          "code": "3599310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE LEFT",
      "code_information": [
        {
          "code": "3599311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE RIGHT",
      "code_information": [
        {
          "code": "3599312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 25GX5”",
      "code_information": [
        {
          "code": "3599313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 251,
          "minimum": 52.71,
          "maximum": 183.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 156.2149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3599314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1037,
          "minimum": 217.77,
          "maximum": 759.2914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 645.3977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXYGENATOR-PERFUSION 050715",
      "code_information": [
        {
          "code": "3599315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1812,
          "minimum": 380.52,
          "maximum": 1326.7464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1127.7344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-Y TYPE PERFUSION 10004",
      "code_information": [
        {
          "code": "3599362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 19G X 1.5\\\"CT",
      "code_information": [
        {
          "code": "3599369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.5515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM TUBING 8H23R12",
      "code_information": [
        {
          "code": "3599370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2383,
          "minimum": 500.43,
          "maximum": 1744.8326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1483.1077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.7/125MM 03.133.105",
      "code_information": [
        {
          "code": "3599378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1325,
          "minimum": 278.25,
          "maximum": 970.165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 824.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-PIECE-OXYGEN MONITOR",
      "code_information": [
        {
          "code": "3599381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.6357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 5ML GIS-55",
      "code_information": [
        {
          "code": "3599412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-FINGER XL A8685",
      "code_information": [
        {
          "code": "3599413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 136.9214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY 040-300",
      "code_information": [
        {
          "code": "3599414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RET 5MM/155CM FB-231D.A",
      "code_information": [
        {
          "code": "3599417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/135X45 03.133.106",
      "code_information": [
        {
          "code": "3599424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1497,
          "minimum": 314.37,
          "maximum": 1096.1034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 931.6879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL N8 PROCESSOR DUALN8",
      "code_information": [
        {
          "code": "3599512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62546,
          "minimum": 13134.66,
          "maximum": 45796.1812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38926.754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0 EPM8703",
      "code_information": [
        {
          "code": "3599513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 901,
          "minimum": 189.21,
          "maximum": 659.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 560.7554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.002",
      "code_information": [
        {
          "code": "3599527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 944,
          "minimum": 198.24,
          "maximum": 691.1968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 587.5173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOYSTICK-RED 5MM 03.211.454",
      "code_information": [
        {
          "code": "3599531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2911,
          "minimum": 611.31,
          "maximum": 2131.4342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1811.7191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IABC 40CC 7FR IMU7F-40",
      "code_information": [
        {
          "code": "3599539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5359,
          "minimum": 1125.39,
          "maximum": 3923.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3335.2808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-SD 2MM T6 313.843.V",
      "code_information": [
        {
          "code": "3599548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1853,
          "minimum": 389.13,
          "maximum": 1356.7666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1153.2516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIX 1.1MM DC4212",
      "code_information": [
        {
          "code": "3599593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 70MM",
      "code_information": [
        {
          "code": "3599601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.0964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 100MM",
      "code_information": [
        {
          "code": "3599602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.0964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE SMALL",
      "code_information": [
        {
          "code": "3599607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE MEDIUM",
      "code_information": [
        {
          "code": "3599608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE LARGE",
      "code_information": [
        {
          "code": "3599609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE X-LARGE",
      "code_information": [
        {
          "code": "3599610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.0476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 3520",
      "code_information": [
        {
          "code": "3599611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4030",
      "code_information": [
        {
          "code": "3599612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4540",
      "code_information": [
        {
          "code": "3599613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5040",
      "code_information": [
        {
          "code": "3599614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.2437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5550",
      "code_information": [
        {
          "code": "3599615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 86.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 35-40CM",
      "code_information": [
        {
          "code": "3599617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 293,
          "minimum": 61.53,
          "maximum": 214.5346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 182.3544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 40-45CM",
      "code_information": [
        {
          "code": "3599618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 293,
          "minimum": 61.53,
          "maximum": 214.5346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 182.3544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE CVD AC-20055390",
      "code_information": [
        {
          "code": "3599638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1368,
          "minimum": 287.28,
          "maximum": 1001.6496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 851.4022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE STRAIGHT",
      "code_information": [
        {
          "code": "3599639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1369,
          "minimum": 287.49,
          "maximum": 1002.3818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 852.0245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .315\\\" NAR 200138107S",
      "code_information": [
        {
          "code": "3599664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .50\\\" WIDE 200138108S",
      "code_information": [
        {
          "code": "3599666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-BONE SCREW IB200051",
      "code_information": [
        {
          "code": "3599670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1584,
          "minimum": 332.64,
          "maximum": 1159.8048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 985.8341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDES-PT SPECIFIC PROPINF",
      "code_information": [
        {
          "code": "3599671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7311,
          "minimum": 1535.31,
          "maximum": 5353.1142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4550.1471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 2.4MM 200072",
      "code_information": [
        {
          "code": "3599672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 349.1496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CORNER 4.8MM 33600048",
      "code_information": [
        {
          "code": "3599673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2020,
          "minimum": 424.2,
          "maximum": 1479.044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1257.1874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACID-5% ACETIC 9045052",
      "code_information": [
        {
          "code": "3599696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.9225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL CARE DUOCARE MDS604DC",
      "code_information": [
        {
          "code": "3599708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.2713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3599751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.0764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-INTERSEPT 6031",
      "code_information": [
        {
          "code": "3599752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X1/4X1/4 Y 6036",
      "code_information": [
        {
          "code": "3599753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/2X3/8X3/8 6040",
      "code_information": [
        {
          "code": "3599754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.0764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PERFUSE 1/4\\\" 10007",
      "code_information": [
        {
          "code": "3599756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/M P01-900-1703",
      "code_information": [
        {
          "code": "3599770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1683.5108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH 82-1516",
      "code_information": [
        {
          "code": "3599774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1505,
          "minimum": 316.05,
          "maximum": 1101.961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 936.6668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOPRO-VASOVIEW 2 VEIN",
      "code_information": [
        {
          "code": "3599778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6789,
          "minimum": 1425.69,
          "maximum": 4970.9058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4225.2699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 5F 20\\\"",
      "code_information": [
        {
          "code": "3599779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 6.5F 36\\\"",
      "code_information": [
        {
          "code": "3599780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.1672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UNIVERSAL PALM MEDIUM",
      "code_information": [
        {
          "code": "3599787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 17GX4.5\\\"",
      "code_information": [
        {
          "code": "3599788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 143.7675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPACER IN-LINE 42-RTC24-VP",
      "code_information": [
        {
          "code": "3599789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRIMARY DUOVENT 1424828",
      "code_information": [
        {
          "code": "3599790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-PED ANES W/FILTER",
      "code_information": [
        {
          "code": "3599791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 143,
          "minimum": 30.03,
          "maximum": 104.7046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.9989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 45MM",
      "code_information": [
        {
          "code": "3599808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2874,
          "minimum": 603.54,
          "maximum": 2104.3428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1788.6914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 60MM",
      "code_information": [
        {
          "code": "3599809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3133,
          "minimum": 657.93,
          "maximum": 2293.9826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1949.8852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 368,
          "minimum": 77.28,
          "maximum": 269.4496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 229.0322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 231.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ATERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.7044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 10CM SHORT",
      "code_information": [
        {
          "code": "3599881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 8CM SHORT",
      "code_information": [
        {
          "code": "3599882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-LP 2MMX4CM RBYLP0204",
      "code_information": [
        {
          "code": "3599885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4457,
          "minimum": 935.97,
          "maximum": 3263.4154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2773.9031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.1X70 KWIRE 03.130.200",
      "code_information": [
        {
          "code": "3599922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5X7 STD AR-7350TD",
      "code_information": [
        {
          "code": "3599951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 689.586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY G 18FR 2.7",
      "code_information": [
        {
          "code": "3599960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 609.9226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING DISP FG-600U",
      "code_information": [
        {
          "code": "3600018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 572.5804,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT 10012",
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        {
          "code": "3600074",
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 47.67,
          "maximum": 166.2094,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/36 7413",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 304.92,
          "maximum": 1063.1544,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 903.6812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PROVOX XTRAFLOW HME",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 10/36",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORA/PARA 6FRTAPS-6F-12PT",
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        {
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        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.3CM",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 127.05,
          "maximum": 442.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNOTOMY 046-367",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 203.91,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 604.3213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-SELF LOCKING 4933-0-802",
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        {
          "code": "3600214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 117.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH14 050179",
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        {
          "code": "3600219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 604.3213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R501-26",
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        {
          "code": "3600220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL XS EVF1XSLA",
      "code_information": [
        {
          "code": "3600221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 157.4596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL S-M EVF1MSLA",
      "code_information": [
        {
          "code": "3600222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 157.4596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL L EVF1LSLA",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SMLSL",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 49.98,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 8 5 165808",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SZ 0 VLOCM2146",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 81.9,
          "maximum": 285.558,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 BARBED VLOCL0615",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 364.0865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X285MM 703583",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R502-15",
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        {
          "code": "3600272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT AR-11114",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 173.0189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO 125MM AR-3210-0051",
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        {
          "code": "3600300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR,SUCTION 8MM 480299",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 392.28,
          "maximum": 1367.7496,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1162.5872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-2.3MM INLINE DRILL MOUTH",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 517.23,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1532.8973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SPIRAL 7000AAO",
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        {
          "code": "3600310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ONESTEP 5F OSC-5F-12PT/C",
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        {
          "code": "3600311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 98.28,
          "maximum": 342.6696,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NASAL ETOC2 ADT",
      "code_information": [
        {
          "code": "3600315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 172.3965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48MM EZOUT 7812-048-001K",
      "code_information": [
        {
          "code": "3600316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3159.7725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-50MM EZOUT 7812-050-001K",
      "code_information": [
        {
          "code": "3600317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3159.7725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC/SAG 5.5 2296-023-412",
      "code_information": [
        {
          "code": "3600318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.2559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FAT TRANS VIALITY-1400",
      "code_information": [
        {
          "code": "3600331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2106.7224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3600343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL 3.5/2.5 AR-8943-14",
      "code_information": [
        {
          "code": "3600344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3998,
          "minimum": 839.58,
          "maximum": 2927.3356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2488.2353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 MONOTEX T8623",
      "code_information": [
        {
          "code": "3600351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-VISION SUCTION PROBE",
      "code_information": [
        {
          "code": "3600353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-VISION PROBE ION 490127",
      "code_information": [
        {
          "code": "3600354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 204.7597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 19G BIOPSY",
      "code_information": [
        {
          "code": "3600355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 21G BIOPSY",
      "code_information": [
        {
          "code": "3600356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 23G BIOPSY",
      "code_information": [
        {
          "code": "3600357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 14-16FR",
      "code_information": [
        {
          "code": "3600358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.7819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-ION SWIVEL",
      "code_information": [
        {
          "code": "3600359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 845.1785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 5X356/126MM 03.008.008",
      "code_information": [
        {
          "code": "3600375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1921,
          "minimum": 403.41,
          "maximum": 1406.5562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1195.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROC 2.3X230 P99-194-2323",
      "code_information": [
        {
          "code": "3600390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 624.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3600412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUMIDIFIER-CPAP HC325S",
      "code_information": [
        {
          "code": "3600428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE M001141006",
      "code_information": [
        {
          "code": "3600430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1293,
          "minimum": 271.53,
          "maximum": 946.7346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 804.7244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-2-2.7MM 706200",
      "code_information": [
        {
          "code": "3600436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 877.5417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-8MM/SD LORD 1088-43-008",
      "code_information": [
        {
          "code": "3600449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2457.7391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-6MM/SD PARA 108843106",
      "code_information": [
        {
          "code": "3600452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2457.7391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER FLX 4150016000",
      "code_information": [
        {
          "code": "3600467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4998,
          "minimum": 1049.58,
          "maximum": 3659.5356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3110.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-9X250 STP 4150002090",
      "code_information": [
        {
          "code": "3600471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1353.6547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-FETAL C-SECTION",
      "code_information": [
        {
          "code": "3600474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3493.3628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-BAND POLY CFI-733",
      "code_information": [
        {
          "code": "3600493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PUMP 8\\\" AR-6411",
      "code_information": [
        {
          "code": "3600498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 476.113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC OUTFLOW AR-6435",
      "code_information": [
        {
          "code": "3600499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 752,
          "minimum": 157.92,
          "maximum": 550.6144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 468.0222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY M00516071",
      "code_information": [
        {
          "code": "3600502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.1872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VEIN HARVEST VASOVIEW",
      "code_information": [
        {
          "code": "3600503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1476,
          "minimum": 309.96,
          "maximum": 1080.7272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 918.6181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURSPLEX DART300 NASAL",
      "code_information": [
        {
          "code": "3600506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURAPLEX DART-REACH600",
      "code_information": [
        {
          "code": "3600507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY O40-403",
      "code_information": [
        {
          "code": "3600508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 4.6X340 P99-110-4634",
      "code_information": [
        {
          "code": "3600519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1742.0136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 11X200 4922-8-200",
      "code_information": [
        {
          "code": "3600545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1786,
          "minimum": 375.06,
          "maximum": 1307.7092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1111.5528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HEMOCON PERF 020271801",
      "code_information": [
        {
          "code": "3600548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 842,
          "minimum": 176.82,
          "maximum": 616.5124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 524.0355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-SINGLE NEOPRENE M8138",
      "code_information": [
        {
          "code": "3600550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION ADULT",
      "code_information": [
        {
          "code": "3600551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION PED",
      "code_information": [
        {
          "code": "3600552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383592",
      "code_information": [
        {
          "code": "3600553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 76.5515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-EAR DISP 4015",
      "code_information": [
        {
          "code": "3600557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 187.9557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG STRT AR-7821",
      "code_information": [
        {
          "code": "3600561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1033.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 10FL AR-9280NOT",
      "code_information": [
        {
          "code": "3600562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 689.586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-NANO 2.8X11 AR-9280NSR",
      "code_information": [
        {
          "code": "3600563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 689.586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-HP EVAC 70 E1CA5874-01",
      "code_information": [
        {
          "code": "3600565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2197,
          "minimum": 461.37,
          "maximum": 1608.6434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1367.3469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-EVAC 70 EICA5872-01",
      "code_information": [
        {
          "code": "3600567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2097,
          "minimum": 440.37,
          "maximum": 1535.4234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1305.1099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE XP EICA8872-01",
      "code_information": [
        {
          "code": "3600568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2093,
          "minimum": 439.53,
          "maximum": 1532.4946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1302.6204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PURPLE",
      "code_information": [
        {
          "code": "3600570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY PURPLE",
      "code_information": [
        {
          "code": "3600571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PINK/RED",
      "code_information": [
        {
          "code": "3600574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY YELLOW",
      "code_information": [
        {
          "code": "3600575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY WHITE",
      "code_information": [
        {
          "code": "3600576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION WHITE",
      "code_information": [
        {
          "code": "3600577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION BLUE",
      "code_information": [
        {
          "code": "3600579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION ORANGE",
      "code_information": [
        {
          "code": "3600580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY ORANGE",
      "code_information": [
        {
          "code": "3600581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION GREEN",
      "code_information": [
        {
          "code": "3600582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GUIDE 95CM/9FR STRT",
      "code_information": [
        {
          "code": "3600599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1186.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 16MM P45-914-0001",
      "code_information": [
        {
          "code": "3600607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-XL 10MM HEX P45-941-0001",
      "code_information": [
        {
          "code": "3600609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 423.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT P45-170-1000",
      "code_information": [
        {
          "code": "3600610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4204.7317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MEASURE STOMA MIC-KEY",
      "code_information": [
        {
          "code": "3600617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 56.6357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENTERAL FEEDING LITE",
      "code_information": [
        {
          "code": "3600618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 85.8871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-FARREL ENTERAL W BAG",
      "code_information": [
        {
          "code": "3600619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 78.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.7MM AR-7511",
      "code_information": [
        {
          "code": "3600664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 WHITE 48360W",
      "code_information": [
        {
          "code": "3600665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1008.8618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLUE 48360B",
      "code_information": [
        {
          "code": "3600666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1008.8618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 GREEN 48360G",
      "code_information": [
        {
          "code": "3600667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1008.8618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLACK 48360T",
      "code_information": [
        {
          "code": "3600668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1008.8618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-PORTABLE DEVILBISS",
      "code_information": [
        {
          "code": "3600669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2011,
          "minimum": 422.31,
          "maximum": 1472.4542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1251.5861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WATER-STERILE INHALATION 500ML",
      "code_information": [
        {
          "code": "3600670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-14FR SU130-1239",
      "code_information": [
        {
          "code": "3600671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2016,
          "minimum": 423.36,
          "maximum": 1476.1152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1254.6979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-16FR SU130-1240",
      "code_information": [
        {
          "code": "3600672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2016,
          "minimum": 423.36,
          "maximum": 1476.1152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1254.6979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-12mm 47050",
      "code_information": [
        {
          "code": "3600674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X185MM 2351-4218S",
      "code_information": [
        {
          "code": "3600681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 809.081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 1.7MM DSDS0017",
      "code_information": [
        {
          "code": "3600688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1186.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2MM DSDS0020",
      "code_information": [
        {
          "code": "3600689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1186.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3600708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 648.5095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.6X150MM AR-8741-16",
      "code_information": [
        {
          "code": "3600710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 382.1352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,-TR 2X8MM AR-300-B002",
      "code_information": [
        {
          "code": "3600711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1535.3868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X3.5MM AR-8741-14",
      "code_information": [
        {
          "code": "3600715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.0233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION AR-200",
      "code_information": [
        {
          "code": "3600717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 245.2138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-3.7MM DRILL AR-2272",
      "code_information": [
        {
          "code": "3600719",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1425,
          "minimum": 299.25,
          "maximum": 1043.385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 886.8773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO POLY M-L 51114V",
      "code_information": [
        {
          "code": "3600722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 48.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CADD PCA 108” 21-7391-24",
      "code_information": [
        {
          "code": "3600723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.102",
      "code_information": [
        {
          "code": "3600736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 X806H",
      "code_information": [
        {
          "code": "3600739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN PVC 24FR",
      "code_information": [
        {
          "code": "3600749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANCHOR-ENTUIT SUTURE G35562",
      "code_information": [
        {
          "code": "3600750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1342,
          "minimum": 281.82,
          "maximum": 982.6124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 835.2205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT FEEDINGTUBE G3561",
      "code_information": [
        {
          "code": "3600751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 482.9591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LEAD-CATH 4FR 38 383069",
      "code_information": [
        {
          "code": "3600757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-NITINOL 2.0MM",
      "code_information": [
        {
          "code": "3600759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6MM MXM-072-16",
      "code_information": [
        {
          "code": "3600767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1119.6436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6 MXM-072-ISO-16",
      "code_information": [
        {
          "code": "3600768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1119.6436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RCC RMH-T015S",
      "code_information": [
        {
          "code": "3600773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 562.6225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXOFIN FUSION EF70430",
      "code_information": [
        {
          "code": "3600781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 976,
          "minimum": 204.96,
          "maximum": 714.6272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 607.4331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 MONOTEX FS-2 T8665",
      "code_information": [
        {
          "code": "3600782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA",
      "code_information": [
        {
          "code": "3600783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.0798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "XTRAFLANGE-PROVOX 20 FR 7276",
      "code_information": [
        {
          "code": "3600784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.0798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20 FR 6MM 8277",
      "code_information": [
        {
          "code": "3600785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1951,
          "minimum": 409.71,
          "maximum": 1428.5222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1214.2439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2006-NS",
      "code_information": [
        {
          "code": "3600786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1816.0757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-NS",
      "code_information": [
        {
          "code": "3600787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1816.0757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-LF",
      "code_information": [
        {
          "code": "3600788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1816.0757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE 4.2X130 2351-4213S",
      "code_information": [
        {
          "code": "3600791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 809.081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-LOCK 4.2X360 2351-4236S",
      "code_information": [
        {
          "code": "3600792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 809.081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-CARDIOTOMY EL400",
      "code_information": [
        {
          "code": "3600858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 579,
          "minimum": 121.59,
          "maximum": 423.9438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 360.3522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 34CC LINEAR",
      "code_information": [
        {
          "code": "3600866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4523,
          "minimum": 949.83,
          "maximum": 3311.7406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2814.9795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 40CC MEGA 0",
      "code_information": [
        {
          "code": "3600867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4905,
          "minimum": 1030.05,
          "maximum": 3591.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3052.7249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 50CC MEGA 0",
      "code_information": [
        {
          "code": "3600868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4905,
          "minimum": 1030.05,
          "maximum": 3591.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3052.7249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-8\\\" THD AR-8967KT",
      "code_information": [
        {
          "code": "3600879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1 LMA",
      "code_information": [
        {
          "code": "3600899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 10' 251010J",
      "code_information": [
        {
          "code": "3600900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-STR 4MM P1-AU511",
      "code_information": [
        {
          "code": "3600906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7067,
          "minimum": 1484.07,
          "maximum": 5174.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4398.2888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1.5 LMA",
      "code_information": [
        {
          "code": "3600907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 3 LMA",
      "code_information": [
        {
          "code": "3600908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 5 LMA",
      "code_information": [
        {
          "code": "3600909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 2 LMA",
      "code_information": [
        {
          "code": "3600910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 45.433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS MED TRACTION",
      "code_information": [
        {
          "code": "3600912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS LG TRACTION",
      "code_information": [
        {
          "code": "3600913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS SM TRACTION",
      "code_information": [
        {
          "code": "3600914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 130187",
      "code_information": [
        {
          "code": "3600915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 72.1949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SHRT SCREW 6149.1042",
      "code_information": [
        {
          "code": "3600925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EZX 54MM BRXTB540",
      "code_information": [
        {
          "code": "3600938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5636,
          "minimum": 1183.56,
          "maximum": 4126.6792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3507.6773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-TOGA XL 0416-830-100",
      "code_information": [
        {
          "code": "3600948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 909,
          "minimum": 190.89,
          "maximum": 665.5698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 565.7343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20F 10MM 8279",
      "code_information": [
        {
          "code": "3600952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1894,
          "minimum": 397.74,
          "maximum": 1386.7868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1178.7688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS MALLEABLE 4MM",
      "code_information": [
        {
          "code": "3600954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1353.6547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG LIGHT MED C02051",
      "code_information": [
        {
          "code": "3600964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG SMALL C020500",
      "code_information": [
        {
          "code": "3600965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 228MM 56010228",
      "code_information": [
        {
          "code": "3600977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-JONES 3.2MM 56013200",
      "code_information": [
        {
          "code": "3600978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1186.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 5.5MM 56015500",
      "code_information": [
        {
          "code": "3600980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1584,
          "minimum": 332.64,
          "maximum": 1159.8048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 985.8341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CRYOTHERAPY FGS-7000",
      "code_information": [
        {
          "code": "3600997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5867,
          "minimum": 1232.07,
          "maximum": 4295.8174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3651.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXHAUST COLLECT FGS-7015",
      "code_information": [
        {
          "code": "3600999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONN-X 5.5/32-40 LNG 1119.0034",
      "code_information": [
        {
          "code": "3601000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1984.1156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-SUCT&ANTICOAG BT275",
      "code_information": [
        {
          "code": "3601009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 121.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ XF 4.2MM 0909-400-400",
      "code_information": [
        {
          "code": "3601031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 435.659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 10MM 650.110",
      "code_information": [
        {
          "code": "3601032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-12\\\" THD AR-8967KT-12",
      "code_information": [
        {
          "code": "3601044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 234.0111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS BIPOLAR 2MM",
      "code_information": [
        {
          "code": "3601053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1667,
          "minimum": 350.07,
          "maximum": 1220.5774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1037.4908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CRV 4MM P1-AU550",
      "code_information": [
        {
          "code": "3601055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4898.0519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-360-430 ALLOX2-FH13SE",
      "code_information": [
        {
          "code": "3601056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7446,
          "minimum": 1563.66,
          "maximum": 5451.9612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4634.167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACENTESIS/PARACENTESI",
      "code_information": [
        {
          "code": "3601066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 701,
          "minimum": 147.21,
          "maximum": 513.2722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 436.2814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G CMNT 0306-150-000",
      "code_information": [
        {
          "code": "3601086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 372.1773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CMNT 11G 0306-330-000",
      "code_information": [
        {
          "code": "3601087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 642,
          "minimum": 134.82,
          "maximum": 470.0724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 399.5615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TB AR-200",
      "code_information": [
        {
          "code": "3601096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 252.6822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRILL 3X320 P31-951-3032",
      "code_information": [
        {
          "code": "3601107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1963,
          "minimum": 412.23,
          "maximum": 1437.3086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1221.7123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 7X200 P99-110-7019",
      "code_information": [
        {
          "code": "3601108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1742.0136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-110-4630",
      "code_information": [
        {
          "code": "3601109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1742.0136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.8X250 P99-100-3825",
      "code_information": [
        {
          "code": "3601110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1742.0136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-100-4630",
      "code_information": [
        {
          "code": "3601111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1742.0136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-HEAD 17.5 03.404.031S",
      "code_information": [
        {
          "code": "3601120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3893,
          "minimum": 817.53,
          "maximum": 2850.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2422.8864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CENTRAL VENOUS PED",
      "code_information": [
        {
          "code": "3601123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 669,
          "minimum": 140.49,
          "maximum": 489.8418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 416.3655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOD-PROTECTOR 69392",
      "code_information": [
        {
          "code": "3601124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 350,
          "minimum": 73.5,
          "maximum": 256.27,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 217.8295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT ADULT DISP 731",
      "code_information": [
        {
          "code": "3601125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 273,
          "minimum": 57.33,
          "maximum": 199.8906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CHEST VENT HYFIN TWINPACK",
      "code_information": [
        {
          "code": "3601126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.67,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-VARISPEED 62-50201",
      "code_information": [
        {
          "code": "3601154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1913,
          "minimum": 401.73,
          "maximum": 1400.6986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1190.5938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.5MM 72202189",
      "code_information": [
        {
          "code": "3601200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STR 14MM/SC 684.424",
      "code_information": [
        {
          "code": "3601216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SUCTION BALLARD 14FR",
      "code_information": [
        {
          "code": "3601234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.0199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 35FR 412351000",
      "code_information": [
        {
          "code": "3601235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 37FR 412371000",
      "code_information": [
        {
          "code": "3601236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1086.0357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 39FR 412391000",
      "code_information": [
        {
          "code": "3601237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1086.0357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-1.8X450 DIA PT 4933-8-010",
      "code_information": [
        {
          "code": "3601244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 682,
          "minimum": 143.22,
          "maximum": 499.3604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 424.4563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 120MM 4933-1-120",
      "code_information": [
        {
          "code": "3601245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 527,
          "minimum": 110.67,
          "maximum": 385.8694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 327.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 150MM 4933-1-150",
      "code_information": [
        {
          "code": "3601246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 527,
          "minimum": 110.67,
          "maximum": 385.8694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 327.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SCREW 6149.1040",
      "code_information": [
        {
          "code": "3601255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-IV SW 3000ML BAG S8505",
      "code_information": [
        {
          "code": "3601260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 93.3555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4MM CANN AR-8973-40S",
      "code_information": [
        {
          "code": "3601272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 972.1419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-PIN & PROT P45-610-1000",
      "code_information": [
        {
          "code": "3601289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 258.2835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-10MM P47-950-0001",
      "code_information": [
        {
          "code": "3601290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1933,
          "minimum": 405.93,
          "maximum": 1415.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1203.0412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-PROTECT P45-600-1000-S",
      "code_information": [
        {
          "code": "3601291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 129.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-AIR+MENISCAL CV 4722",
      "code_information": [
        {
          "code": "3601324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1587.6659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLUE STAPLE GCR40B",
      "code_information": [
        {
          "code": "3601345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1903,
          "minimum": 399.63,
          "maximum": 1393.3766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1184.3701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-GRAFT LG M00236320021",
      "code_information": [
        {
          "code": "3601349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 176,
          "minimum": 36.96,
          "maximum": 128.8672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 109.5371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC SMALL 313-9013W",
      "code_information": [
        {
          "code": "3601350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 176.1307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC MED 313-9014W",
      "code_information": [
        {
          "code": "3601351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 176.1307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC LARGE 313-9015W",
      "code_information": [
        {
          "code": "3601352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 176.1307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-2.5 PRCSN MTCH HD 16CM",
      "code_information": [
        {
          "code": "3601354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1891,
          "minimum": 397.11,
          "maximum": 1384.5902,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1176.9017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROCH 1.1MM AR-18700-30",
      "code_information": [
        {
          "code": "3601375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STEP SOLID 1806-3026S",
      "code_information": [
        {
          "code": "3601387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1432,
          "minimum": 300.72,
          "maximum": 1048.5104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 891.2338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47522",
      "code_information": [
        {
          "code": "3601390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 779.8296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47520",
      "code_information": [
        {
          "code": "3601391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 779.8296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-ENDOCLOT EA230",
      "code_information": [
        {
          "code": "3601393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 592,
          "minimum": 124.32,
          "maximum": 433.4624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 12\\\" 3.2MM",
      "code_information": [
        {
          "code": "3601397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 399,
          "minimum": 83.79,
          "maximum": 292.1478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 248.3256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.25MM  AR-18800-35",
      "code_information": [
        {
          "code": "3601403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 851,
          "minimum": 178.71,
          "maximum": 623.1022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 529.6369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-10X16X8/12° 1213.6088S",
      "code_information": [
        {
          "code": "3601406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6769,
          "minimum": 1421.49,
          "maximum": 4956.2618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4212.8225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 16X8MM 1128.2408",
      "code_information": [
        {
          "code": "3601407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2808.7558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X14MM 184.014",
      "code_information": [
        {
          "code": "3601408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X16MM 184.016",
      "code_information": [
        {
          "code": "3601409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR SD 4.2X14MM 184.054",
      "code_information": [
        {
          "code": "3601410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI REFLUX",
      "code_information": [
        {
          "code": "3601418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-KANGAROO Y-PORT/PEG",
      "code_information": [
        {
          "code": "3601419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 18FR 8887605189",
      "code_information": [
        {
          "code": "3601420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 20FR 8887605205",
      "code_information": [
        {
          "code": "3601421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IN/OUTFLOW AR-6436",
      "code_information": [
        {
          "code": "3601433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1031,
          "minimum": 216.51,
          "maximum": 754.8982,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 641.6635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-3X7 AR-9300DS",
      "code_information": [
        {
          "code": "3601434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 514.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 382.1352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON PEG ENFIT",
      "code_information": [
        {
          "code": "3601438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.3699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G-TUBE ENFIT",
      "code_information": [
        {
          "code": "3601440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1234,
          "minimum": 259.14,
          "maximum": 903.5348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 768.0046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG ENFIT 24FR M00509061",
      "code_information": [
        {
          "code": "3601441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 439.3932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5020",
      "code_information": [
        {
          "code": "3601445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 846,
          "minimum": 177.66,
          "maximum": 619.4412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 526.525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOCKWAVE STERILE CABLE",
      "code_information": [
        {
          "code": "3601446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16FR 20CM G01212",
      "code_information": [
        {
          "code": "3601447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-18FR 20CM G01328",
      "code_information": [
        {
          "code": "3601448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO JEJUNAL 8250-22",
      "code_information": [
        {
          "code": "3601452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1577,
          "minimum": 331.17,
          "maximum": 1154.6794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 981.4775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 8200-20",
      "code_information": [
        {
          "code": "3601453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 861.3601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10FR 50-7361",
      "code_information": [
        {
          "code": "3601454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 444,
          "minimum": 93.24,
          "maximum": 325.0968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.3323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 18140",
      "code_information": [
        {
          "code": "3601455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 609.9226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN 2.55MM MD 45303155",
      "code_information": [
        {
          "code": "3601456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DLP CORONARY 30315",
      "code_information": [
        {
          "code": "3601479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 510,
          "minimum": 107.1,
          "maximum": 373.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 317.4087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 875,
          "minimum": 183.75,
          "maximum": 640.675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 544.5738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 14FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.3699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.3699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC DRG MN12050",
      "code_information": [
        {
          "code": "3601484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1671.0634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PREFORM-S3-4 39+6MM DWP2396",
      "code_information": [
        {
          "code": "3601576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5055.5115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 18X7MM 1128.1507",
      "code_information": [
        {
          "code": "3601577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2808.7558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-20X55 8-17 5° 1122.1055",
      "code_information": [
        {
          "code": "3601578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 31589,
          "minimum": 6633.69,
          "maximum": 23129.4658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 19660.0459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 3X14 AR-8630-14",
      "code_information": [
        {
          "code": "3601580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.9072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 2.5X16 AR-8625-16",
      "code_information": [
        {
          "code": "3601581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.9072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LP/CRT 1.6X9 AR-18716-09",
      "code_information": [
        {
          "code": "3601582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1206,
          "minimum": 253.26,
          "maximum": 883.0332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 750.5782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CABLE PLATE 94-1200-08",
      "code_information": [
        {
          "code": "3601588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5867,
          "minimum": 1232.07,
          "maximum": 4295.8174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3651.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1195",
      "code_information": [
        {
          "code": "3601590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.0976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ1 CN P2ND1001",
      "code_information": [
        {
          "code": "3601591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 936.0445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-PEDI DSG P2HE2000",
      "code_information": [
        {
          "code": "3601592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8710,
          "minimum": 1829.1,
          "maximum": 6377.462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5420.8427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BALLARD/NEO BAA2103",
      "code_information": [
        {
          "code": "3601615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.3345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-DF 65MM/RT/STD 6495-2-040",
      "code_information": [
        {
          "code": "3601630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21681,
          "minimum": 4553.01,
          "maximum": 15874.8282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13493.604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CN/CC 7X45MM 8040-045",
      "code_information": [
        {
          "code": "3601631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1732.6781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-SMALL KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7523,
          "minimum": 1579.83,
          "maximum": 5508.3406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4682.0895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-LARGE KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7523,
          "minimum": 1579.83,
          "maximum": 5508.3406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4682.0895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 11X100MM 4922-8-100",
      "code_information": [
        {
          "code": "3601641",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1743,
          "minimum": 366.03,
          "maximum": 1276.2246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1084.7909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-WOUND CROWN",
      "code_information": [
        {
          "code": "3601647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 490.4276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN RAL 6MM B02236010",
      "code_information": [
        {
          "code": "3601652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1566.5053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN STD 6MM B02236001",
      "code_information": [
        {
          "code": "3601653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1566.5053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL LK 3.5 AR-8943-43",
      "code_information": [
        {
          "code": "3601667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1666.7069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ALEXIS M/L HR105",
      "code_information": [
        {
          "code": "3601692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1086.0357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5 SHORT 6149.1038S",
      "code_information": [
        {
          "code": "3601700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLEY-COUVEL 3-W",
      "code_information": [
        {
          "code": "3601705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-O3 OXIMETRY CEREBRAL",
      "code_information": [
        {
          "code": "3601707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM",
      "code_information": [
        {
          "code": "3601709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1691.6017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM BOX",
      "code_information": [
        {
          "code": "3601710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2537,
          "minimum": 532.77,
          "maximum": 1857.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1578.9527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 23/M P01-900-2303",
      "code_information": [
        {
          "code": "3601722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1683.5108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ2 CN P2ND1002",
      "code_information": [
        {
          "code": "3601743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 936.0445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 16FR",
      "code_information": [
        {
          "code": "3601752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 609.9226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CV/XS 4MM P1-AU551",
      "code_information": [
        {
          "code": "3601759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4898.0519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 3/10F AR-98300OBT",
      "code_information": [
        {
          "code": "3601764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 514.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CIR/BEV P45-940-1001",
      "code_information": [
        {
          "code": "3601766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.0MM",
      "code_information": [
        {
          "code": "3601769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FLIPCUTTER III AR-1204FF",
      "code_information": [
        {
          "code": "3601777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2543,
          "minimum": 534.03,
          "maximum": 1861.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1582.6869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MGS 3MM AR-9628S",
      "code_information": [
        {
          "code": "3601781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.9072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-INFANT NEONATE CO2",
      "code_information": [
        {
          "code": "3601783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCAN 4MM AR-1204D",
      "code_information": [
        {
          "code": "3601799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1261,
          "minimum": 264.81,
          "maximum": 923.3042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 784.8086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-.066CN 2.75MM AR-7000-14",
      "code_information": [
        {
          "code": "3601800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1535.3868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X6\\\" AR-8941-6",
      "code_information": [
        {
          "code": "3601803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X7\\\" AR-8941-7",
      "code_information": [
        {
          "code": "3601804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG ST TR AR-7823",
      "code_information": [
        {
          "code": "3601805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1033.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TROCH 1.35MM AR-8737-02",
      "code_information": [
        {
          "code": "3601814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 195.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JTIP 8164-2001-25",
      "code_information": [
        {
          "code": "3601822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 47.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRAY AR-200SP",
      "code_information": [
        {
          "code": "3601873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1232.2926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G MIS SHARP 501168",
      "code_information": [
        {
          "code": "3601880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE 6MM BH-220",
      "code_information": [
        {
          "code": "3601882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11846,
          "minimum": 2487.66,
          "maximum": 8673.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7372.595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMAN.157X9\\\" KI71675",
      "code_information": [
        {
          "code": "3601893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 193,
          "minimum": 40.53,
          "maximum": 141.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.1174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .035X9\\\" DD KI71211",
      "code_information": [
        {
          "code": "3601894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FRACTURE KEX152EB",
      "code_information": [
        {
          "code": "3601895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 13504,
          "minimum": 2835.84,
          "maximum": 9887.6288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8404.4845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-TIB 11X360MM 1822-1136S",
      "code_information": [
        {
          "code": "3601898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5142,
          "minimum": 1079.82,
          "maximum": 3764.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3200.2265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LASER TRACH #5 102004050",
      "code_information": [
        {
          "code": "3601900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1245,
          "minimum": 261.45,
          "maximum": 911.589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 774.8506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-BLOOD COLLECT 04258",
      "code_information": [
        {
          "code": "3601933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 364.0865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77720",
      "code_information": [
        {
          "code": "3601934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 744,
          "minimum": 156.24,
          "maximum": 544.7568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 463.0433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .062X5\\\" 5050-249",
      "code_information": [
        {
          "code": "3601939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 143,
          "minimum": 30.03,
          "maximum": 104.7046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.9989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .045X5\\\" 5050-248",
      "code_information": [
        {
          "code": "3601940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 64.1041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLUTION-WOUND VASHE 16OZ 003",
      "code_information": [
        {
          "code": "3601945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX944",
      "code_information": [
        {
          "code": "3601947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 173.0189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM AO 702473",
      "code_information": [
        {
          "code": "3601950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2131,
          "minimum": 447.51,
          "maximum": 1560.3182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1326.2705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-7MM P20-910-7000",
      "code_information": [
        {
          "code": "3601961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1072.3435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXT-PERCUTANEOUS 9009",
      "code_information": [
        {
          "code": "3601976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 624.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 400MM BT 693.060S",
      "code_information": [
        {
          "code": "3601978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 326.7442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM 1032-115-000",
      "code_information": [
        {
          "code": "3601985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10370,
          "minimum": 2177.7,
          "maximum": 7592.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6453.9769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM 2PROBE 9700-020-200",
      "code_information": [
        {
          "code": "3601986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20104,
          "minimum": 4221.84,
          "maximum": 14720.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 12512.1265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-AEOS STERILE PV012SU",
      "code_information": [
        {
          "code": "3601989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 462,
          "minimum": 97.02,
          "maximum": 338.2764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA 22FR 77422",
      "code_information": [
        {
          "code": "3601990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 347.9048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ENDO 5MM 174209",
      "code_information": [
        {
          "code": "3601996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1819,
          "minimum": 381.99,
          "maximum": 1331.8718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1132.091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 6213-119-070",
      "code_information": [
        {
          "code": "3601997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PURESOME TMD-07",
      "code_information": [
        {
          "code": "3601998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 217.2071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM AR-8943-36",
      "code_information": [
        {
          "code": "3602028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1198,
          "minimum": 251.58,
          "maximum": 877.1756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 745.5993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PED LUMBAR 21G 645",
      "code_information": [
        {
          "code": "3602032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 136.299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN HEEL 10X10",
      "code_information": [
        {
          "code": "3602037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.7752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X C/D",
      "code_information": [
        {
          "code": "3602043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X C/D",
      "code_information": [
        {
          "code": "3602044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 179.2426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X C/D",
      "code_information": [
        {
          "code": "3602045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL C/D",
      "code_information": [
        {
          "code": "3602046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG C/D",
      "code_information": [
        {
          "code": "3602047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED C/D",
      "code_information": [
        {
          "code": "3602048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K SMALL C/D",
      "code_information": [
        {
          "code": "3602049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X A/B",
      "code_information": [
        {
          "code": "3602050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X A/B",
      "code_information": [
        {
          "code": "3602051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X A/B",
      "code_information": [
        {
          "code": "3602052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 179.2426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL A/B",
      "code_information": [
        {
          "code": "3602053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG A/B",
      "code_information": [
        {
          "code": "3602054",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 215.9624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED A/B",
      "code_information": [
        {
          "code": "3602055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN CMP 2.2 DSDS0022",
      "code_information": [
        {
          "code": "3602079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1186.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-JOINT PREP INST 9914PK01",
      "code_information": [
        {
          "code": "3602083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1461.9471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP 1.1 NT/SM 58820006",
      "code_information": [
        {
          "code": "3602084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 752,
          "minimum": 157.92,
          "maximum": 550.6144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 468.0222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MICA 2X12MM 57SR0212",
      "code_information": [
        {
          "code": "3602085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2772,
          "minimum": 582.12,
          "maximum": 2029.6584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1725.2096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MICA INST BLADE 57S1MI07",
      "code_information": [
        {
          "code": "3602088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2242,
          "minimum": 470.82,
          "maximum": 1641.5924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1395.3535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAMPATNCY FGS-0668",
      "code_information": [
        {
          "code": "3602103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRUDI SHAVER TSB4STR",
      "code_information": [
        {
          "code": "3602104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1984.1156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-BIENAIR AQUACARE 1600617",
      "code_information": [
        {
          "code": "3602106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-ORGO IRRIGATION 1502152",
      "code_information": [
        {
          "code": "3602107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 162.4386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-OSTOMY 18665",
      "code_information": [
        {
          "code": "3602109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-CLOSED TUBE 1320-0125S",
      "code_information": [
        {
          "code": "3602113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 596.8528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 724G",
      "code_information": [
        {
          "code": "3602121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0 8756H",
      "code_information": [
        {
          "code": "3602122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0   8717H",
      "code_information": [
        {
          "code": "3602124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.0753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-EVARREST 2x4\\\" EVT5024",
      "code_information": [
        {
          "code": "3602126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4700,
          "minimum": 987,
          "maximum": 3441.34,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2925.139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-6 LEAD ECG SNAP BR-916PA",
      "code_information": [
        {
          "code": "3602128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1080,
          "minimum": 226.8,
          "maximum": 790.776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 672.1596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE",
      "code_information": [
        {
          "code": "3602129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TRI 4.0MM P1-AU411",
      "code_information": [
        {
          "code": "3602153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7067,
          "minimum": 1484.07,
          "maximum": 5174.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4398.2888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1086.0357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.8705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.2693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.9072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1732.6781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 713.236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 C012D",
      "code_information": [
        {
          "code": "3602196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 102.0687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1033.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2506.9064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1086.0357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.8705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.2693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.9072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1732.6781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 713.236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3164,
          "minimum": 664.44,
          "maximum": 2316.6808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1969.1787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2506.9064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1033.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-END +5 HUM 1830-0005S",
      "code_information": [
        {
          "code": "3602288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1128,
          "minimum": 236.88,
          "maximum": 825.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 702.0334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1086.0357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.8705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.2693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1733.3004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 713.236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT DL 15MM PROBE 9700-015-200",
      "code_information": [
        {
          "code": "3602331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 22350,
          "minimum": 4693.5,
          "maximum": 16364.67,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13909.9695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2506.9064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3164,
          "minimum": 664.44,
          "maximum": 2316.6808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1969.1787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2185,
          "minimum": 458.85,
          "maximum": 1599.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1359.8784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2506.9064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1033.7566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1086.0357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 296.8705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.2693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.9072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1732.6781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 713.236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT 125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5426,
          "minimum": 1139.46,
          "maximum": 3972.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3376.9796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2185,
          "minimum": 458.85,
          "maximum": 1599.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1359.8784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5426,
          "minimum": 1139.46,
          "maximum": 3972.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3376.9796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 13MM 7786713",
      "code_information": [
        {
          "code": "3602404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 7786703",
      "code_information": [
        {
          "code": "3602405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-MDI SPACER M 1082715",
      "code_information": [
        {
          "code": "3602410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.3488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRXPERION XP65/115VS",
      "code_information": [
        {
          "code": "3602411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 152.4806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH SZ5/90MM A0A14",
      "code_information": [
        {
          "code": "3602422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON LINEAR 40",
      "code_information": [
        {
          "code": "3602462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5202,
          "minimum": 1092.42,
          "maximum": 3808.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3237.5687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 111331",
      "code_information": [
        {
          "code": "3602483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 601.2094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SKIN CLOSURE CLR602US",
      "code_information": [
        {
          "code": "3602486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1556,
          "minimum": 326.76,
          "maximum": 1139.3032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 968.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-RADIAN FACET K 5526061",
      "code_information": [
        {
          "code": "3602487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1514,
          "minimum": 317.94,
          "maximum": 1108.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 942.2682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 11MM 7786711",
      "code_information": [
        {
          "code": "3602491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PELVIC STAB T-PODR",
      "code_information": [
        {
          "code": "3602497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 581.9159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIR-G BL-NOSE 3X900 0101-900S",
      "code_information": [
        {
          "code": "3602503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 779.8296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165MM S0210-200",
      "code_information": [
        {
          "code": "3602508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1940,
          "minimum": 407.4,
          "maximum": 1420.468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1207.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OPEN REAMER 03.168.004",
      "code_information": [
        {
          "code": "3602515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8067,
          "minimum": 1694.07,
          "maximum": 5906.6574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 5020.6588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3X413MM 03.168.011",
      "code_information": [
        {
          "code": "3602516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3163,
          "minimum": 664.23,
          "maximum": 2315.9486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1968.5563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LOWER 8/+0 END 2330-0000S",
      "code_information": [
        {
          "code": "3602538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1299,
          "minimum": 272.79,
          "maximum": 951.1278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 808.4586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEART LOOP AV 9S44R",
      "code_information": [
        {
          "code": "3602540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 326.7442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-LOW PROFILE 6143.2527",
      "code_information": [
        {
          "code": "3602541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6702,
          "minimum": 1407.42,
          "maximum": 4907.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4171.1237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 160MM P45-180-0160",
      "code_information": [
        {
          "code": "3602542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4045,
          "minimum": 849.45,
          "maximum": 2961.749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2517.4866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 160MM P45-112-0140",
      "code_information": [
        {
          "code": "3602543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4204.7317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-G BALL 3X550 P31-955-1550",
      "code_information": [
        {
          "code": "3602544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1963,
          "minimum": 412.23,
          "maximum": 1437.3086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1221.7123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-300MM THRED P45-310-0300",
      "code_information": [
        {
          "code": "3602545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.7399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRUTS-QA MOD MD P45-224-0170",
      "code_information": [
        {
          "code": "3602546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6214,
          "minimum": 1304.94,
          "maximum": 4549.8908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3867.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INST ARAGONITE MINI-DS",
      "code_information": [
        {
          "code": "3602550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1253.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOINT-BALL MOD P45-233-1000",
      "code_information": [
        {
          "code": "3602557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE 1.8 P99-202-1810",
      "code_information": [
        {
          "code": "3602569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 662.824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCPP41D",
      "code_information": [
        {
          "code": "3602572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 112.649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PRONE LAT STAB 6246.0200",
      "code_information": [
        {
          "code": "3602576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7446,
          "minimum": 1563.66,
          "maximum": 5451.9612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4634.167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TT 2.4X9.25 AR-8870K",
      "code_information": [
        {
          "code": "3602593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 235,
          "minimum": 49.35,
          "maximum": 172.067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 146.2569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT W/CAP",
      "code_information": [
        {
          "code": "3602596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT 205-212",
      "code_information": [
        {
          "code": "3602597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT WAVE+ 3.9M",
      "code_information": [
        {
          "code": "3602598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2984.2641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT FLEX 2.9MM",
      "code_information": [
        {
          "code": "3602599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2808.7558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT SMOL 2.9MM",
      "code_information": [
        {
          "code": "3602600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3012,
          "minimum": 632.52,
          "maximum": 2205.3864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1874.5784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3602604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4897,
          "minimum": 1028.37,
          "maximum": 3585.5834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3047.7459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3602606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4897,
          "minimum": 1028.37,
          "maximum": 3585.5834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3047.7459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.2L CN AR-8973-32LS",
      "code_information": [
        {
          "code": "3602614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 972.1419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°RT AR-4068-90R",
      "code_information": [
        {
          "code": "3602617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 909.9049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°LT AR-4068-90L",
      "code_information": [
        {
          "code": "3602618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 955.3379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°LT AR-4068-45L",
      "code_information": [
        {
          "code": "3602619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 955.3379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°RT AR-4068-45R",
      "code_information": [
        {
          "code": "3602620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 955.3379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPLEDAM AR-6530TD",
      "code_information": [
        {
          "code": "3602621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 249.5704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DTRAX SPINAL DX-22-300",
      "code_information": [
        {
          "code": "3602622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3159.7725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS 11G/5\\\"\\\" 0306-116-000",
      "code_information": [
        {
          "code": "3602624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 774,
          "minimum": 162.54,
          "maximum": 566.7228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 481.7144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-OPTIFIX ABSORB 0113126",
      "code_information": [
        {
          "code": "3602652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HAWKINS 18GX15CM G05045",
      "code_information": [
        {
          "code": "3602657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 14FR G00996",
      "code_information": [
        {
          "code": "3602678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.2437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 12FR G00995",
      "code_information": [
        {
          "code": "3602679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-MWCE-18S-4/2-TORNADO",
      "code_information": [
        {
          "code": "3602685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1086,
          "minimum": 228.06,
          "maximum": 795.1692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 675.8938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-10-8 MREYE",
      "code_information": [
        {
          "code": "3602686",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-8 MREYE G42423",
      "code_information": [
        {
          "code": "3602687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION MREYE G42414",
      "code_information": [
        {
          "code": "3602690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-5 MREYE G42410",
      "code_information": [
        {
          "code": "3602691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-4 MREYE G42409",
      "code_information": [
        {
          "code": "3602692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-3 MREYE G42408",
      "code_information": [
        {
          "code": "3602693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-2-3 MREYE G42406",
      "code_information": [
        {
          "code": "3602694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 15MM X 15G",
      "code_information": [
        {
          "code": "3602699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1426,
          "minimum": 299.46,
          "maximum": 1044.1172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 887.4996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 25MM X 15G",
      "code_information": [
        {
          "code": "3602700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1426,
          "minimum": 299.46,
          "maximum": 1044.1172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 887.4996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CO 2.10MM NS1806.002 STE",
      "code_information": [
        {
          "code": "3602710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1658,
          "minimum": 348.18,
          "maximum": 1213.9876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1031.8895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2883-01-024",
      "code_information": [
        {
          "code": "3602763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1645,
          "minimum": 345.45,
          "maximum": 1204.469,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1023.7986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC SAW 1.27MM 71440375",
      "code_information": [
        {
          "code": "3602770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 460.5538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X340MM 1806-4260S",
      "code_information": [
        {
          "code": "3602772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1134,
          "minimum": 238.14,
          "maximum": 830.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 705.7676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 13X300MM 351.27",
      "code_information": [
        {
          "code": "3602773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3542,
          "minimum": 743.82,
          "maximum": 2593.4524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2204.4345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 360.05S",
      "code_information": [
        {
          "code": "3602774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4064,
          "minimum": 853.44,
          "maximum": 2975.6608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2529.3117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 38FR 68138",
      "code_information": [
        {
          "code": "3602784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 462,
          "minimum": 97.02,
          "maximum": 338.2764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/15CM CA1815",
      "code_information": [
        {
          "code": "3602790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 30FR 68130",
      "code_information": [
        {
          "code": "3602796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 358.4851,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 32FR 68132",
      "code_information": [
        {
          "code": "3602797",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 602,
          "minimum": 126.42,
          "maximum": 440.7844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 374.6667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 36FR 68136",
      "code_information": [
        {
          "code": "3602798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 358.4851,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 34FR 68134",
      "code_information": [
        {
          "code": "3602799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR",
      "code_information": [
        {
          "code": "3602805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 436,
          "minimum": 91.56,
          "maximum": 319.2392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 271.3533,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94895",
      "code_information": [
        {
          "code": "3602818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 647.8872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94835",
      "code_information": [
        {
          "code": "3602819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 647.8872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3602851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 794.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 16G/15CM CA1615",
      "code_information": [
        {
          "code": "3602858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 14G/11CM CA1411",
      "code_information": [
        {
          "code": "3602859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.2758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 X523H",
      "code_information": [
        {
          "code": "3602867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0  X513H",
      "code_information": [
        {
          "code": "3602868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 41.6988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7 W/QC STD TP 71933035",
      "code_information": [
        {
          "code": "3602893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1420.2483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X250 AO 1806-8018S",
      "code_information": [
        {
          "code": "3602902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.7255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-W/ NEEDLES #0 SUTURE",
      "code_information": [
        {
          "code": "3602933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1879.5574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-EXTREMITIES UNIVERSAL",
      "code_information": [
        {
          "code": "3602935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1194",
      "code_information": [
        {
          "code": "3602936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.0976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ201",
      "code_information": [
        {
          "code": "3602938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2106.7224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ101",
      "code_information": [
        {
          "code": "3602939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2106.7224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 180MM P45-112-0180",
      "code_information": [
        {
          "code": "3602943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4204.7317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 180MM P45-180-0180",
      "code_information": [
        {
          "code": "3602944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4045,
          "minimum": 849.45,
          "maximum": 2961.749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2517.4866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-4H THRED P45-921-0004",
      "code_information": [
        {
          "code": "3602945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2618,
          "minimum": 549.78,
          "maximum": 1916.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1629.3647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CALIBRA 4X165MM 0225-000",
      "code_information": [
        {
          "code": "3602953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2376,
          "minimum": 498.96,
          "maximum": 1739.7072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1478.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5MMPINX9.5MMROD 1151-200",
      "code_information": [
        {
          "code": "3602954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3458,
          "minimum": 726.18,
          "maximum": 2531.9476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2152.1555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-9.5 X 9.5MM ROD 1151-200",
      "code_information": [
        {
          "code": "3602955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3458,
          "minimum": 726.18,
          "maximum": 2531.9476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2152.1555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X150MM 1152-150",
      "code_information": [
        {
          "code": "3602956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X200MM 1152-200",
      "code_information": [
        {
          "code": "3602957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X250MM 1152-250",
      "code_information": [
        {
          "code": "3602958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X300 1152-300",
      "code_information": [
        {
          "code": "3602959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN ASSEM 1158-000",
      "code_information": [
        {
          "code": "3602960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6458,
          "minimum": 1356.18,
          "maximum": 4728.5476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4019.2655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VENASEAL CLOSURE VS-404",
      "code_information": [
        {
          "code": "3602966",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3072.0183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-5.5 P20-910-5500",
      "code_information": [
        {
          "code": "3602974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1072.3435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK -.5 P20-915-5500",
      "code_information": [
        {
          "code": "3602976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1072.3435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PROTECT 5.0 P45-198-5000",
      "code_information": [
        {
          "code": "3602978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5320",
      "code_information": [
        {
          "code": "3603015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1167,
          "minimum": 245.07,
          "maximum": 854.4774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 726.3058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-150MM THRED P45-310-0150",
      "code_information": [
        {
          "code": "3603022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 423.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-CUBE 4H P45-925-0004",
      "code_information": [
        {
          "code": "3603023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2738,
          "minimum": 574.98,
          "maximum": 2004.7636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1704.0491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-3/16\\\" SQ P99-000-316P",
      "code_information": [
        {
          "code": "3603028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 8MM P45-914-0003",
      "code_information": [
        {
          "code": "3603029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCRW-POST+NUT SET B0223000",
      "code_information": [
        {
          "code": "3603037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1566.5053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.35MM AR-5050-01",
      "code_information": [
        {
          "code": "3603040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ULTRALOOP-HS FIBER 72205445",
      "code_information": [
        {
          "code": "3603051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 536.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM PROBE 9700-020-100",
      "code_information": [
        {
          "code": "3603057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21773,
          "minimum": 4572.33,
          "maximum": 15942.1906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13550.862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/F P01-900-1702",
      "code_information": [
        {
          "code": "3603060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1683.5108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F40 64611",
      "code_information": [
        {
          "code": "3603068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63306",
      "code_information": [
        {
          "code": "3603069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63305",
      "code_information": [
        {
          "code": "3603070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE SMALL",
      "code_information": [
        {
          "code": "3603071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.7952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE LARGE",
      "code_information": [
        {
          "code": "3603072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.7952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE MEDIUM",
      "code_information": [
        {
          "code": "3603073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.7952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYNG SZ4 321400000U",
      "code_information": [
        {
          "code": "3603074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL WIDE",
      "code_information": [
        {
          "code": "3603075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL FITPACK",
      "code_information": [
        {
          "code": "3603076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 120.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOWS-SOLO FITPACK SLP1SMSLA",
      "code_information": [
        {
          "code": "3603077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X400MM 1152-400",
      "code_information": [
        {
          "code": "3603081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1437.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP427H",
      "code_information": [
        {
          "code": "3603082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOULTION-WOUND VASHE 118ML",
      "code_information": [
        {
          "code": "3603095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 225,
          "minimum": 47.25,
          "maximum": 164.745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 140.0332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ULTRABRAID SZ2 7210915",
      "code_information": [
        {
          "code": "3603096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.9137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-50 COBLATION 72290037",
      "code_information": [
        {
          "code": "3603101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1887,
          "minimum": 396.27,
          "maximum": 1381.6614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1174.4122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3603102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 517,
          "minimum": 108.57,
          "maximum": 378.5474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 321.7653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-5.5 72202530",
      "code_information": [
        {
          "code": "3603103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 682.7399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-HRVST SYS SK27",
      "code_information": [
        {
          "code": "3603104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3493.3628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INST-GUIDE RELEASE SN20",
      "code_information": [
        {
          "code": "3603105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-HK BONE REMOVAL SN25",
      "code_information": [
        {
          "code": "3603107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRIPLE EDGE INST SN21",
      "code_information": [
        {
          "code": "3603108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0 C013D",
      "code_information": [
        {
          "code": "3603114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 101.4463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-FILSHIE AVM-851J",
      "code_information": [
        {
          "code": "3603115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1434,
          "minimum": 301.14,
          "maximum": 1049.9748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 892.4786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERC SUTURE AR-7267",
      "code_information": [
        {
          "code": "3603119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 14MM 2022-30-014S",
      "code_information": [
        {
          "code": "3603135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 994.5473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 16MM 2022-30-016S",
      "code_information": [
        {
          "code": "3603136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 994.5473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PIN PROT WHT 5027-1-040",
      "code_information": [
        {
          "code": "3603139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREADED CTF03",
      "code_information": [
        {
          "code": "3603177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3603179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2984.2641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3603180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2984.2641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 8F",
      "code_information": [
        {
          "code": "3603181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2984.2641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 9F",
      "code_information": [
        {
          "code": "3603182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2984.2641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 8MM 022108-10",
      "code_information": [
        {
          "code": "3603183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TPR 3MM 5407-FA3-030",
      "code_information": [
        {
          "code": "3603184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1282,
          "minimum": 269.22,
          "maximum": 938.6804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 797.8783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 6MM 5820-010-160",
      "code_information": [
        {
          "code": "3603185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 929.8208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RASP-HELI 3.2MM 5120-080-030",
      "code_information": [
        {
          "code": "3603186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1446,
          "minimum": 303.66,
          "maximum": 1058.7612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 899.947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 7205306",
      "code_information": [
        {
          "code": "3603188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 283.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 1683H",
      "code_information": [
        {
          "code": "3603192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3603196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3050,
          "minimum": 640.5,
          "maximum": 2233.21,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1898.2285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT C0R47",
      "code_information": [
        {
          "code": "3603197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS CFF74",
      "code_information": [
        {
          "code": "3603198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEEDLE WINGED INF WNIS01",
      "code_information": [
        {
          "code": "3603199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 67.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED CTF73",
      "code_information": [
        {
          "code": "3603214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANN-VENOUS HI FLO 24FR 69324",
      "code_information": [
        {
          "code": "3603215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 257.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A404",
      "code_information": [
        {
          "code": "3603218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 244.5914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR 72201513",
      "code_information": [
        {
          "code": "3603219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 656,
          "minimum": 137.76,
          "maximum": 480.3232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.2747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3603221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 615,
          "minimum": 129.15,
          "maximum": 450.303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 382.7575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOVIE-E-Z CLEAN 0014A",
      "code_information": [
        {
          "code": "3603224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.6777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SOMFIT 7037-1001-00",
      "code_information": [
        {
          "code": "3603227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MOD 12MM 2022-30-012S",
      "code_information": [
        {
          "code": "3603247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 994.5473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3603277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-ZINC OXIDE REMDEY 4OZ",
      "code_information": [
        {
          "code": "3603279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.6777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT X 2.4/45° 378824",
      "code_information": [
        {
          "code": "3603290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 308,
          "minimum": 64.68,
          "maximum": 225.5176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-STR SP 15° 378235",
      "code_information": [
        {
          "code": "3603291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.2713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM BP 0808-115-800",
      "code_information": [
        {
          "code": "3603299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10281,
          "minimum": 2159.01,
          "maximum": 7527.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6398.586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-11G VP 0605-411-000",
      "code_information": [
        {
          "code": "3603300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2421,
          "minimum": 508.41,
          "maximum": 1772.6562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1506.7578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-10G VP 0605-410-000",
      "code_information": [
        {
          "code": "3603301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2421,
          "minimum": 508.41,
          "maximum": 1772.6562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1506.7578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BL 3X600 AR-9091BK-30S",
      "code_information": [
        {
          "code": "3603303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL 4.2MM AR-9091-42",
      "code_information": [
        {
          "code": "3603304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1775.6216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CM VP 11G 0306-511-000",
      "code_information": [
        {
          "code": "3603319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 604,
          "minimum": 126.84,
          "maximum": 442.2488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 375.9115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5 REAMING 6143.2571",
      "code_information": [
        {
          "code": "3603340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1879.5574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM F/ANCHOR 72203785",
      "code_information": [
        {
          "code": "3603349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1506,
          "minimum": 316.26,
          "maximum": 1102.6932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 937.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X5MM 60-16005",
      "code_information": [
        {
          "code": "3603351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 799.1231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X26MM 60-16526",
      "code_information": [
        {
          "code": "3603355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1442,
          "minimum": 302.82,
          "maximum": 1055.8324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 897.4575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X35 92-16135",
      "code_information": [
        {
          "code": "3603356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1863,
          "minimum": 391.23,
          "maximum": 1364.0886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1159.4753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X50/5M 60-15105",
      "code_information": [
        {
          "code": "3603363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1488,
          "minimum": 312.48,
          "maximum": 1089.5136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 926.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X110/20M 60-15620",
      "code_information": [
        {
          "code": "3603364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1691.6017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 VICRYL PLUS VCP762D",
      "code_information": [
        {
          "code": "3603378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 133.1872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13X50/13G NN-2003",
      "code_information": [
        {
          "code": "3603396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13340.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL DIST 2.8MM 4040-000",
      "code_information": [
        {
          "code": "3603404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1975,
          "minimum": 414.75,
          "maximum": 1446.095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1229.1807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 1.5X230MM 0109-230",
      "code_information": [
        {
          "code": "3603406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 713.236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE HAND 415S002350",
      "code_information": [
        {
          "code": "3603407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1545.3447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CIRCUIT NEONATE DUAL LIMB",
      "code_information": [
        {
          "code": "3603429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 754,
          "minimum": 158.34,
          "maximum": 552.0788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 469.267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SUCTION TABLE 8Q70R",
      "code_information": [
        {
          "code": "3603430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 633,
          "minimum": 132.93,
          "maximum": 463.4826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 393.9602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5X150 CN P41-910-5015",
      "code_information": [
        {
          "code": "3603431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1018.1973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGATION P65-001-0006-SK",
      "code_information": [
        {
          "code": "3603437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1316,
          "minimum": 276.36,
          "maximum": 963.5752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 819.0389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-QUAD TIP 2762-01-0003",
      "code_information": [
        {
          "code": "3603444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1963.5774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2.5CM M00510880",
      "code_information": [
        {
          "code": "3603498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2CM M00510870",
      "code_information": [
        {
          "code": "3603499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GENERATOR-RF PROC RLVRFGPR",
      "code_information": [
        {
          "code": "3603504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1148.895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ADD ACCESS INST RLV0075",
      "code_information": [
        {
          "code": "3603508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2457.7391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ACCESS INSTRUMENT RLV0045",
      "code_information": [
        {
          "code": "3603510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9838,
          "minimum": 2065.98,
          "maximum": 7203.3836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6122.8761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DAVINCI INSUFF TUBE 470551",
      "code_information": [
        {
          "code": "3603512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1264,
          "minimum": 265.44,
          "maximum": 925.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 786.6757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/10CM NN-8006",
      "code_information": [
        {
          "code": "3603527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 16702,
          "minimum": 3507.42,
          "maximum": 12229.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 10394.8237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X60/13G NN-2004",
      "code_information": [
        {
          "code": "3603530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13340.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 40X11 SM-4011M",
      "code_information": [
        {
          "code": "3603538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ALLOGRAFT-22.5MM ABS-4057D-225",
      "code_information": [
        {
          "code": "3603542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5686,
          "minimum": 1194.06,
          "maximum": 4163.2892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3538.7958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL-1.5x48MM 03.130.212",
      "code_information": [
        {
          "code": "3603544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 644.153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP76",
      "code_information": [
        {
          "code": "3603545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 138.7885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE 9X102 HTOE 05-306",
      "code_information": [
        {
          "code": "3603547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 245.2138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.35X150 AR-8943-01S",
      "code_information": [
        {
          "code": "3603548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLECTOR-SPECIMEN NN-9002",
      "code_information": [
        {
          "code": "3603569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 435.659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/13CM NN-8007",
      "code_information": [
        {
          "code": "3603587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 18660,
          "minimum": 3918.6,
          "maximum": 13662.852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 11613.4242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X95/13G NN-2006",
      "code_information": [
        {
          "code": "3603588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13340.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X75/13G NN-2005",
      "code_information": [
        {
          "code": "3603589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 13340.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-MYRID NICO NN-9001",
      "code_information": [
        {
          "code": "3603590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 70.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 7FRX65C",
      "code_information": [
        {
          "code": "3603592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1624,
          "minimum": 341.04,
          "maximum": 1189.0928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1010.7289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 5FRX50C",
      "code_information": [
        {
          "code": "3603593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1624,
          "minimum": 341.04,
          "maximum": 1189.0928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1010.7289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 9FRX65C",
      "code_information": [
        {
          "code": "3603594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1882,
          "minimum": 395.22,
          "maximum": 1378.0004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1171.3003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-20-22FR/45CM G52835",
      "code_information": [
        {
          "code": "3603768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1759,
          "minimum": 369.39,
          "maximum": 1287.9398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1094.7488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16-18FR/45CM G52834",
      "code_information": [
        {
          "code": "3603769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1759,
          "minimum": 369.39,
          "maximum": 1287.9398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1094.7488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-32-35MM 102024003",
      "code_information": [
        {
          "code": "3603771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.4X27 ST 60-14126",
      "code_information": [
        {
          "code": "3603794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.0754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOWN-WARMING BEAR PAW 81001",
      "code_information": [
        {
          "code": "3603809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 107.67,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPYSCOPE DS II M00546610",
      "code_information": [
        {
          "code": "3603810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12212,
          "minimum": 2564.52,
          "maximum": 8941.6264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7600.3824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-EHL 1.9F 375CM M00546620",
      "code_information": [
        {
          "code": "3603814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2879,
          "minimum": 604.59,
          "maximum": 2108.0038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1791.8032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONEMILL MD 5420-MED-000",
      "code_information": [
        {
          "code": "3603815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3354,
          "minimum": 704.34,
          "maximum": 2455.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2087.429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CRV DIAMOND 15° 1600650",
      "code_information": [
        {
          "code": "3603818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CYLINDER 60° 1600578",
      "code_information": [
        {
          "code": "3603819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.9X27MM 60-19126",
      "code_information": [
        {
          "code": "3603820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 692.0754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X200MM P99-192-1620",
      "code_information": [
        {
          "code": "3603836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 624.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2.0 3846T",
      "code_information": [
        {
          "code": "3603837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7.4684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y415H",
      "code_information": [
        {
          "code": "3603838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 7.4684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 7-0 Z135H",
      "code_information": [
        {
          "code": "3603876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 273,
          "minimum": 57.33,
          "maximum": 199.8906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 45X6 SM-4506",
      "code_information": [
        {
          "code": "3603888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-38MM ARS743201",
      "code_information": [
        {
          "code": "3603895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 977.7433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-14X127MM ARS743303",
      "code_information": [
        {
          "code": "3603897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 977.7433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE .9MM 57S90005",
      "code_information": [
        {
          "code": "3603901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 401.4287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE 1.4MM 57S90004",
      "code_information": [
        {
          "code": "3603902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 401.4287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM MXM-072-19",
      "code_information": [
        {
          "code": "3603904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1119.6436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-76/3 ARS743202",
      "code_information": [
        {
          "code": "3603910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 977.7433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 8.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603923",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 6.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SM CHLD NR34015813",
      "code_information": [
        {
          "code": "3603926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015814",
      "code_information": [
        {
          "code": "3603927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 55.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PRO-FLOW NR37000145",
      "code_information": [
        {
          "code": "3603928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SPO2 ADULT NR37004030",
      "code_information": [
        {
          "code": "3603929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 50.412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMETRY EM951160CP",
      "code_information": [
        {
          "code": "3603931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.9635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ADULT NR34015818",
      "code_information": [
        {
          "code": "3603932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.6777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASALNR354S5011",
      "code_information": [
        {
          "code": "3603933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.7198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015816",
      "code_information": [
        {
          "code": "3603934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG WEBB NR104B1420",
      "code_information": [
        {
          "code": "3603935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 81.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-EEG 8OZ NR10200005",
      "code_information": [
        {
          "code": "3603936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 529,
          "minimum": 111.09,
          "maximum": 387.3338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 329.2337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUPREP-4OZ TUBE NR10210004",
      "code_information": [
        {
          "code": "3603937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.3345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THERMOCAN NR34015808",
      "code_information": [
        {
          "code": "3603938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.7198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR/6.7MM 80220",
      "code_information": [
        {
          "code": "3603955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 240.8572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CLEARVUE LARYNG #3",
      "code_information": [
        {
          "code": "3603957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NOMOLINE LH NASAL/ORAL",
      "code_information": [
        {
          "code": "3603958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 129.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 22FR BE2050",
      "code_information": [
        {
          "code": "3603960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 741.2427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 18FR BE6050",
      "code_information": [
        {
          "code": "3603961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 741.2427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LITHOTRIPER PROBE 3.9MM",
      "code_information": [
        {
          "code": "3603972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4400,
          "minimum": 924,
          "maximum": 3221.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2738.428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T-15 TORQUE 702750",
      "code_information": [
        {
          "code": "3603979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3611,
          "minimum": 758.31,
          "maximum": 2643.9742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2247.3781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIMITER-TORQUE 2.5NM 702760",
      "code_information": [
        {
          "code": "3603985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4015,
          "minimum": 843.15,
          "maximum": 2939.783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2498.8155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/15 STPL THN00482",
      "code_information": [
        {
          "code": "3603988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2099,
          "minimum": 440.79,
          "maximum": 1536.8878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1306.3546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/20 STPL THN00483",
      "code_information": [
        {
          "code": "3603989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2099,
          "minimum": 440.79,
          "maximum": 1536.8878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1306.3546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA 22.5FR 7275",
      "code_information": [
        {
          "code": "3604022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM*CLEARIFY 21-345",
      "code_information": [
        {
          "code": "3604025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 CHROMIC GUT 792G",
      "code_information": [
        {
          "code": "3604027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 155.5925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-NANO 29.5X7MM SM-3115",
      "code_information": [
        {
          "code": "3604043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-MET 20MM MPN20120",
      "code_information": [
        {
          "code": "3604048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHAL 20MM MPN20020",
      "code_information": [
        {
          "code": "3604049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM SHT MSTD1030",
      "code_information": [
        {
          "code": "3604050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CIRCUMCISION 1.45CM",
      "code_information": [
        {
          "code": "3604060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 605,
          "minimum": 127.05,
          "maximum": 442.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 376.5338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE DUAL 844023S",
      "code_information": [
        {
          "code": "3604137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 291,
          "minimum": 61.11,
          "maximum": 213.0702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 181.1097,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE SINGLE 800099S",
      "code_information": [
        {
          "code": "3604138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.6634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 2X200 MSG20200",
      "code_information": [
        {
          "code": "3604156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 445.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.6 F/5.5MM MSN10013",
      "code_information": [
        {
          "code": "3604157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1691.6017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM LNG MSTD0030",
      "code_information": [
        {
          "code": "3604158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 747.4664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA-G GENERATION 2",
      "code_information": [
        {
          "code": "3604162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10740,
          "minimum": 2255.4,
          "maximum": 7863.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6684.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-STAPLE SZ THN00292",
      "code_information": [
        {
          "code": "3604165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1253.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 5.0MM 3100-01-0005",
      "code_information": [
        {
          "code": "3604167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2089.2961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 2.4MM 2900-04-0229",
      "code_information": [
        {
          "code": "3604168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1431,
          "minimum": 300.51,
          "maximum": 1047.7782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 890.6115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-6.5MM 3100-01-0007",
      "code_information": [
        {
          "code": "3604169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2089.2961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-7X90 3200-01-7090",
      "code_information": [
        {
          "code": "3604170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 15795,
          "minimum": 3316.95,
          "maximum": 11565.099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 9830.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SONATA DE-001-10",
      "code_information": [
        {
          "code": "3604172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 877,
          "minimum": 184.17,
          "maximum": 642.1394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 545.8185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS BONE BX 0306-115-000",
      "code_information": [
        {
          "code": "3604196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 798,
          "minimum": 167.58,
          "maximum": 584.2956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 496.6513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-DSG XS 2.5MM P1-AU514",
      "code_information": [
        {
          "code": "3604197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4898.0519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DISTRACTOR 12MM 02.600.022",
      "code_information": [
        {
          "code": "3604198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 617.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-#0/8\\\"\\\" GREEN VLOCA008L",
      "code_information": [
        {
          "code": "3604209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1317,
          "minimum": 276.57,
          "maximum": 964.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 819.6613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VICRYL VCP104G",
      "code_information": [
        {
          "code": "3604215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX977",
      "code_information": [
        {
          "code": "3604217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MINITAPE-LOOPED 72205435",
      "code_information": [
        {
          "code": "3604218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 913,
          "minimum": 191.73,
          "maximum": 668.4986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 568.2238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATE STD 20MM M0056183",
      "code_information": [
        {
          "code": "3604224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 297,
          "minimum": 62.37,
          "maximum": 217.4634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 184.8439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ACESSA 7300",
      "code_information": [
        {
          "code": "3604227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14892,
          "minimum": 3127.32,
          "maximum": 10903.9224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 9268.334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-HEAD SILVERMAN SZ F",
      "code_information": [
        {
          "code": "3604228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X12MM AR-300-B003",
      "code_information": [
        {
          "code": "3604244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1535.3868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 3.1X20MM AR-300-B202",
      "code_information": [
        {
          "code": "3604247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1535.3868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUT 2 P41-960-0020",
      "code_information": [
        {
          "code": "3604263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1072.3435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5.5X150 CN P41-910-5515",
      "code_information": [
        {
          "code": "3604264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1018.1973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X150 CN P41-910-4015",
      "code_information": [
        {
          "code": "3604265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1018.1973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-GPS LONG 6143.2515",
      "code_information": [
        {
          "code": "3604278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6702,
          "minimum": 1407.42,
          "maximum": 4907.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4171.1237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 8.0",
      "code_information": [
        {
          "code": "3604284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 7.5",
      "code_information": [
        {
          "code": "3604285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED",
      "code_information": [
        {
          "code": "3604286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER TRACH PORTEX 100",
      "code_information": [
        {
          "code": "3604287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 36.0975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEMALE TO FEMALE",
      "code_information": [
        {
          "code": "3604289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-1.8MM PERK AR-3610PK-3",
      "code_information": [
        {
          "code": "3604294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1586,
          "minimum": 333.06,
          "maximum": 1161.2692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 987.0788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 6X7 AR-6535TD",
      "code_information": [
        {
          "code": "3604297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 249.5704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SR8 GEMINI AR-6572",
      "code_information": [
        {
          "code": "3604301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 249.5704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLSRE SKN 22CM EF70401",
      "code_information": [
        {
          "code": "3604305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 711,
          "minimum": 149.31,
          "maximum": 520.5942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 442.5051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH 14 1/4\\\" 020116801",
      "code_information": [
        {
          "code": "3604307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-TISSUE HIGH EX71010",
      "code_information": [
        {
          "code": "3604311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.6634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7/F 2.4 AR-8916-18",
      "code_information": [
        {
          "code": "3604317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 334.2127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-WIRE FIX XL 76-10104",
      "code_information": [
        {
          "code": "3604319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1375,
          "minimum": 288.75,
          "maximum": 1006.775,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 855.7587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR PEDIATRIC S-1003",
      "code_information": [
        {
          "code": "3604329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 264,
          "minimum": 55.44,
          "maximum": 193.3008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 164.3057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT SHORT 71-6130S",
      "code_information": [
        {
          "code": "3604330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10354,
          "minimum": 2174.34,
          "maximum": 7581.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6444.019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 4H 76-10140",
      "code_information": [
        {
          "code": "3604333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1053.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 2H 76-10125",
      "code_information": [
        {
          "code": "3604334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1053.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 200MM 76-11200",
      "code_information": [
        {
          "code": "3604335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 716.3479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 115MM 76-11115",
      "code_information": [
        {
          "code": "3604337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 934,
          "minimum": 196.14,
          "maximum": 683.8748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 581.2936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FH 4.2MM AR-9091F-42",
      "code_information": [
        {
          "code": "3604351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1775.6216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CON 4.3X13MM AR-300-B101",
      "code_information": [
        {
          "code": "3604352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2470,
          "minimum": 518.7,
          "maximum": 1808.534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1537.2539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE SKIN EF70466",
      "code_information": [
        {
          "code": "3604355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 933,
          "minimum": 195.93,
          "maximum": 683.1426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 580.6712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEN-ADHESIVE EP70412",
      "code_information": [
        {
          "code": "3604356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.8937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACTIVALVE-PROVOX STRONG 7161",
      "code_information": [
        {
          "code": "3604357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2457.7391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET ACCESS INST LV3 RLV0055",
      "code_information": [
        {
          "code": "3604369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12997,
          "minimum": 2729.37,
          "maximum": 9516.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8088.9429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.6X200 AR-5050K-1",
      "code_information": [
        {
          "code": "3604376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 297.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM C P01-901-0901-S",
      "code_information": [
        {
          "code": "3604385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1683.5108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET SCREW T7 5560010000",
      "code_information": [
        {
          "code": "3604395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 549.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-FOGARTY DSOFT33",
      "code_information": [
        {
          "code": "3604398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 224.6756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-DRAIN/FLUSH LL AFA-LL",
      "code_information": [
        {
          "code": "3604403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #4",
      "code_information": [
        {
          "code": "3604406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 252.6822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #3",
      "code_information": [
        {
          "code": "3604407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 252.6822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-6 THD/10 HEX 76-10180",
      "code_information": [
        {
          "code": "3604415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 235,
          "minimum": 49.35,
          "maximum": 172.067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 146.2569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-FLANGE 10HX 76-10182",
      "code_information": [
        {
          "code": "3604416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 196.0465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD +3OS/25MM MWJ007",
      "code_information": [
        {
          "code": "3604423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5858,
          "minimum": 1230.18,
          "maximum": 4289.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3645.8435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODEL-REV BONE MWJ015",
      "code_information": [
        {
          "code": "3604424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.0 A-3938",
      "code_information": [
        {
          "code": "3604432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2061,
          "minimum": 432.81,
          "maximum": 1509.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1282.7046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 16FR 26-016",
      "code_information": [
        {
          "code": "3604433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 566.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 12FR 26-012",
      "code_information": [
        {
          "code": "3604434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 566.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 18FR 26-018",
      "code_information": [
        {
          "code": "3604435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 566.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-NYLON 11MM/265ML CD005",
      "code_information": [
        {
          "code": "3604438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 408.8971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-6X150 CN P41-910-6015",
      "code_information": [
        {
          "code": "3604457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1018.1973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CAL 5.5MM S0288-200",
      "code_information": [
        {
          "code": "3604470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2470,
          "minimum": 518.7,
          "maximum": 1808.534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1537.2539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.6MM TRC AR-18700-71",
      "code_information": [
        {
          "code": "3604479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 186.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO",
      "code_information": [
        {
          "code": "3604489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 686,
          "minimum": 144.06,
          "maximum": 502.2892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 426.9458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1069210",
      "code_information": [
        {
          "code": "3604490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.6634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-HO 7/1.6X80 P99-205-1608",
      "code_information": [
        {
          "code": "3604512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 662.824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GRAFT SIZING AR-1676ST",
      "code_information": [
        {
          "code": "3604518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1293.9072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMANN .157X9\\\"\\\" KI71615",
      "code_information": [
        {
          "code": "3604550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 122.6069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL SP-78105",
      "code_information": [
        {
          "code": "3604567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 792.8994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 1MM 5820-013-010",
      "code_information": [
        {
          "code": "3604568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 794.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 12X18/2 DS24",
      "code_information": [
        {
          "code": "3604569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 769,
          "minimum": 161.49,
          "maximum": 563.0618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 478.6025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/0 DS26",
      "code_information": [
        {
          "code": "3604570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 832,
          "minimum": 174.72,
          "maximum": 609.1904,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 517.8118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/2 DS28",
      "code_information": [
        {
          "code": "3604571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 815,
          "minimum": 171.15,
          "maximum": 596.743,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 507.2315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 29/37 TF2937O",
      "code_information": [
        {
          "code": "3604581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 379.6457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-AMPLATZ 8F M0062601010",
      "code_information": [
        {
          "code": "3604584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 481,
          "minimum": 101.01,
          "maximum": 352.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 299.36,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-33MM LF EVERGRIP33",
      "code_information": [
        {
          "code": "3604594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 359,
          "minimum": 75.39,
          "maximum": 262.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.4308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEM 19F/6.3 96570-119",
      "code_information": [
        {
          "code": "3604596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2245,
          "minimum": 471.45,
          "maximum": 1643.789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1397.2206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 19F/6.3MM 96530-119",
      "code_information": [
        {
          "code": "3604597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1545.3447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 21F/7MM 96530-121",
      "code_information": [
        {
          "code": "3604598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1545.3447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WHITE 15X12MM DLP-W11",
      "code_information": [
        {
          "code": "3604599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-YELLOW 15X12MM DLP-S11",
      "code_information": [
        {
          "code": "3604600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-11MM 261222",
      "code_information": [
        {
          "code": "3604605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1666.7069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 650-750CC SZHP68650",
      "code_information": [
        {
          "code": "3604611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 550-640CC SZHP68550",
      "code_information": [
        {
          "code": "3604612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 425-455CC SZHP68425",
      "code_information": [
        {
          "code": "3604613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 267.6191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 320-340CC SZHP68320",
      "code_information": [
        {
          "code": "3604614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 341.6811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 200-260CC SZHP68200",
      "code_information": [
        {
          "code": "3604615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 750-800CC SZHP68750",
      "code_information": [
        {
          "code": "3604616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 495.4065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 2MM 5820-010-120",
      "code_information": [
        {
          "code": "3604621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 3MM 5820-010-130",
      "code_information": [
        {
          "code": "3604622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 4MM 5820-010-140",
      "code_information": [
        {
          "code": "3604623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 3MM 5820-012-030",
      "code_information": [
        {
          "code": "3604624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 794.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 4MM 5820-012-040",
      "code_information": [
        {
          "code": "3604625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 929.8208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 3 5820-013-030",
      "code_information": [
        {
          "code": "3604626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 4 5820-013-040",
      "code_information": [
        {
          "code": "3604627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 849.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SAHARA S-1150-08LF",
      "code_information": [
        {
          "code": "3604628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1182,
          "minimum": 248.22,
          "maximum": 865.4604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 735.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 20FR 123120",
      "code_information": [
        {
          "code": "3604629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12X150MM FE CFF71",
      "code_information": [
        {
          "code": "3604631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 199.7808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X150MM FE CFF01",
      "code_information": [
        {
          "code": "3604632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X100MM BLADE CFB03",
      "code_information": [
        {
          "code": "3604633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 167.4175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 9MM 022109-10",
      "code_information": [
        {
          "code": "3604634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 10MM 022110-10",
      "code_information": [
        {
          "code": "3604635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 12MM 022112-10",
      "code_information": [
        {
          "code": "3604636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 57.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 14MM 022114-10",
      "code_information": [
        {
          "code": "3604637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 60.3699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 16MM 022116-10",
      "code_information": [
        {
          "code": "3604638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 65.9712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC 3-0 VLOCM0644",
      "code_information": [
        {
          "code": "3604653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 336.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO BULL M0068332451",
      "code_information": [
        {
          "code": "3604654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.7232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0 M0068331371",
      "code_information": [
        {
          "code": "3604655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 331.7232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-JP SUCT 10MM SU130-1311",
      "code_information": [
        {
          "code": "3604656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 10F SU130-402D",
      "code_information": [
        {
          "code": "3604657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 127,
          "minimum": 26.67,
          "maximum": 92.9894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 79.041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MUSCLE-TRAINING DEVICE",
      "code_information": [
        {
          "code": "3604659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 205.3821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ACORN 5MM 5820-030-550",
      "code_information": [
        {
          "code": "3604667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 929.8208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERY 2X14MM 31200",
      "code_information": [
        {
          "code": "3604670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 549.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERY 1.5X14MM 31150",
      "code_information": [
        {
          "code": "3604671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 549.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCES 8MM IAS8-120LP",
      "code_information": [
        {
          "code": "3604725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 942,
          "minimum": 197.82,
          "maximum": 689.7324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 586.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM ECS29B",
      "code_information": [
        {
          "code": "3604726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2143,
          "minimum": 450.03,
          "maximum": 1569.1046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1333.7389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOULDER LG/18-19.5\\\"\\\"",
      "code_information": [
        {
          "code": "3604728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 401.4287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOULDER M/16.5-18\\\"\\\"",
      "code_information": [
        {
          "code": "3604729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 401.4287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4MM 080-403",
      "code_information": [
        {
          "code": "3604730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 158.082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LARGE COMBO AR-8964-07",
      "code_information": [
        {
          "code": "3604737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1732.2,
          "minimum": 363.762,
          "maximum": 1268.3168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1078.0693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN LG AR-8964-08",
      "code_information": [
        {
          "code": "3604738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1396.5,
          "minimum": 293.265,
          "maximum": 1022.5173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 869.1397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ATTACH-ROD LG CLMP AR-8964-09",
      "code_information": [
        {
          "code": "3604739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1309,
          "minimum": 274.89,
          "maximum": 958.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 814.6823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 100 AR-8964R-100",
      "code_information": [
        {
          "code": "3604740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591.5,
          "minimum": 124.215,
          "maximum": 433.0963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 250 AR-8964R-250",
      "code_information": [
        {
          "code": "3604741",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591.5,
          "minimum": 124.215,
          "maximum": 433.0963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 300 AR-8964R-300",
      "code_information": [
        {
          "code": "3604742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 665,
          "minimum": 139.65,
          "maximum": 486.913,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 413.876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 3.5X195MM AR-8964-10",
      "code_information": [
        {
          "code": "3604743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 332.5,
          "minimum": 69.825,
          "maximum": 243.4565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 206.938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-END CAP AR-8964-22",
      "code_information": [
        {
          "code": "3604744",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REMV FIBULOCK AR-8973RK",
      "code_information": [
        {
          "code": "3604749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6093,
          "minimum": 1279.53,
          "maximum": 4461.2946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3792.1004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3604769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 648.5095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LARGE COMBO AR-8964-07",
      "code_information": [
        {
          "code": "3604775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2067.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN LG AR-8964-08",
      "code_information": [
        {
          "code": "3604776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1666.7069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ATTACH-ROD LG CLMP AR-8964-09",
      "code_information": [
        {
          "code": "3604777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2510,
          "minimum": 527.1,
          "maximum": 1837.822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1562.1487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 3.5X195MM AR-8964-10",
      "code_information": [
        {
          "code": "3604781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 617.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-END CAP AR-8964-22",
      "code_information": [
        {
          "code": "3604782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD CTR/25MM MWJ005",
      "code_information": [
        {
          "code": "3604783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5858,
          "minimum": 1230.18,
          "maximum": 4289.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3645.8435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3X215MM 542053",
      "code_information": [
        {
          "code": "3604785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1886,
          "minimum": 396.06,
          "maximum": 1380.9292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1173.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X215MM 542051",
      "code_information": [
        {
          "code": "3604786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1776,
          "minimum": 372.96,
          "maximum": 1300.3872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1105.3291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPM-SOFT GOODS",
      "code_information": [
        {
          "code": "3604787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 202.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBGAUZE*SURGITUBE SZ 5/8\\\"",
      "code_information": [
        {
          "code": "3604794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 88.3765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR XS 11MM 10/BX",
      "code_information": [
        {
          "code": "3604795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 592,
          "minimum": 124.32,
          "maximum": 433.4624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 368.443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR Y 1/4x1/4x1/4",
      "code_information": [
        {
          "code": "3604798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 81.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO HF 125 AR-3210-0052",
      "code_information": [
        {
          "code": "3604799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 696.5,
          "minimum": 146.265,
          "maximum": 509.9773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 433.4807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.5X215MM 542021",
      "code_information": [
        {
          "code": "3604823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1885,
          "minimum": 395.85,
          "maximum": 1380.197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1173.1674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT AO 93MM 542031",
      "code_information": [
        {
          "code": "3604824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3667,
          "minimum": 770.07,
          "maximum": 2684.9774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2282.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT AO 180MM 542032",
      "code_information": [
        {
          "code": "3604825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2457.7391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 3.5X135MM 542022",
      "code_information": [
        {
          "code": "3604832",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1664,
          "minimum": 349.44,
          "maximum": 1218.3808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1035.6237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-POVIDONE IODINE 5% 192401",
      "code_information": [
        {
          "code": "3604834",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 126.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165 AR-9095-43S",
      "code_information": [
        {
          "code": "3604868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1941,
          "minimum": 407.61,
          "maximum": 1421.2002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1208.0202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SX DRY 13CM PSS13DF-5",
      "code_information": [
        {
          "code": "3604876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1671,
          "minimum": 350.91,
          "maximum": 1223.5062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1039.9803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD T-MAX 7210559",
      "code_information": [
        {
          "code": "3604877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 249.5704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 542000",
      "code_information": [
        {
          "code": "3604891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1626,
          "minimum": 341.46,
          "maximum": 1190.5572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1011.9736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER 60-6085-201A",
      "code_information": [
        {
          "code": "3604912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 529.0145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XL/19.5-22\\\"\\\"",
      "code_information": [
        {
          "code": "3604916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 401.4287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH 6MM NIM 8229706",
      "code_information": [
        {
          "code": "3604917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.1188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH 8MM NIM 8229708",
      "code_information": [
        {
          "code": "3604918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1717.1188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-LEAD 518-024",
      "code_information": [
        {
          "code": "3604919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-BULLDOG LEAD LR-LED01",
      "code_information": [
        {
          "code": "3604933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2457,
          "minimum": 515.97,
          "maximum": 1799.0154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1529.1631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 7X7 AR-6570TD",
      "code_information": [
        {
          "code": "3604936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 249.5704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X125MM 542002",
      "code_information": [
        {
          "code": "3604942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1702,
          "minimum": 357.42,
          "maximum": 1246.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1059.2737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-NEURO PDCMF-BP-001",
      "code_information": [
        {
          "code": "3604949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1148.895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRITOME 3WAY SN31",
      "code_information": [
        {
          "code": "3604952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1649.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEXUS CONNECTORS BP6866N",
      "code_information": [
        {
          "code": "3604957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-LEG SM/16-20\\\"\\\" LS101",
      "code_information": [
        {
          "code": "3604958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 367.8207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 5-0 VCP834G",
      "code_information": [
        {
          "code": "3604959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 51.0343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-SINSKEY 45 /10MM 581442",
      "code_information": [
        {
          "code": "3604965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 371,
          "minimum": 77.91,
          "maximum": 271.6462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 230.8993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-AGILIS HISPRO DS3A001",
      "code_information": [
        {
          "code": "3604978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.1507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LONG INSERTION 40555",
      "code_information": [
        {
          "code": "3604987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3349,
          "minimum": 703.29,
          "maximum": 2452.1378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2084.3171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY VIAL HH9006",
      "code_information": [
        {
          "code": "3604989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3536,
          "minimum": 742.56,
          "maximum": 2589.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2200.7003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRL 4MM CLOSED AR-1595TC",
      "code_information": [
        {
          "code": "3605014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 853.2693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.5X250 SQC 76-10047",
      "code_information": [
        {
          "code": "3605028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2009,
          "minimum": 421.89,
          "maximum": 1470.9898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1250.3413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM CENTERING 76-10210",
      "code_information": [
        {
          "code": "3605029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 934,
          "minimum": 196.14,
          "maximum": 683.8748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 581.2936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 5H 76-10145",
      "code_information": [
        {
          "code": "3605031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1053.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-6X8MM RANCHO 76-10165",
      "code_information": [
        {
          "code": "3605032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 234.0111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-180MM BUTT 71-61180",
      "code_information": [
        {
          "code": "3605034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1053.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-150MM BUTT 71-61150",
      "code_information": [
        {
          "code": "3605035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1053.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARCH-FOOT 150MM 71-90150",
      "code_information": [
        {
          "code": "3605036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5854,
          "minimum": 1229.34,
          "maximum": 4286.2988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3643.354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FOOT 150MM LONG 71-6100L",
      "code_information": [
        {
          "code": "3605037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9905,
          "minimum": 2080.05,
          "maximum": 7252.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 6164.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 155MM 71-10155",
      "code_information": [
        {
          "code": "3605038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6752,
          "minimum": 1417.92,
          "maximum": 4943.8144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4202.2422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 ETHIBOND 10X86N",
      "code_information": [
        {
          "code": "3605039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 484,
          "minimum": 101.64,
          "maximum": 354.3848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 301.2271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-STONE COLLECT XUSM0031",
      "code_information": [
        {
          "code": "3605040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 503,
          "minimum": 105.63,
          "maximum": 368.2966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 313.0521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AP LNG/LT AR-8954-10",
      "code_information": [
        {
          "code": "3605076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3379,
          "minimum": 709.59,
          "maximum": 2474.1038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2102.9882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-GIGLI SAW 260-104",
      "code_information": [
        {
          "code": "3605086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 87.7542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IMPELLA AXILLARY 0052-0011",
      "code_information": [
        {
          "code": "3605088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURESTEP MALE EXT CATH",
      "code_information": [
        {
          "code": "3605089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURESTEP MALE EXT CATH",
      "code_information": [
        {
          "code": "3605090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.8106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV 22G X 2.5\\\" 4251622-02",
      "code_information": [
        {
          "code": "3605091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 83.3976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TPR 3.2/3.9X450 1420-0065S",
      "code_information": [
        {
          "code": "3605102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 792.8994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNAL #6 14\\\" 040-365",
      "code_information": [
        {
          "code": "3605111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1245,
          "minimum": 261.45,
          "maximum": 911.589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 774.8506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EXT 1.2 MICRON FILTER",
      "code_information": [
        {
          "code": "3605116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 42.9435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO ST 90 AR-4068-90",
      "code_information": [
        {
          "code": "3605127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 955.3379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP EXT 6.2/3.2",
      "code_information": [
        {
          "code": "3605137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1232.2926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP NORM 4.9/2.2",
      "code_information": [
        {
          "code": "3605138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1232.2926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-HIP S5/38.5X105 7000-6605",
      "code_information": [
        {
          "code": "3699561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7456,
          "minimum": 1565.76,
          "maximum": 5459.2832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 4640.3907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-JEWETT TLSO S/M REGULAR",
      "code_information": [
        {
          "code": "3699634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 847.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 15M",
      "code_information": [
        {
          "code": "3700007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3512,
          "minimum": 737.52,
          "maximum": 2571.4864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2185.7634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORPREP    260700",
      "code_information": [
        {
          "code": "3800580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 33.608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORQUE-DEVICE           46-550",
      "code_information": [
        {
          "code": "3801395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-18G BARE NEEDLE 78060",
      "code_information": [
        {
          "code": "3820010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1115,
          "minimum": 234.15,
          "maximum": 816.403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 693.9425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 18X6     618735",
      "code_information": [
        {
          "code": "3820055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2797,
          "minimum": 587.37,
          "maximum": 2047.9634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1740.7689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 22X6     618743",
      "code_information": [
        {
          "code": "3820057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1742.0136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 25x6 611771",
      "code_information": [
        {
          "code": "3820062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3718,
          "minimum": 780.78,
          "maximum": 2722.3196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2313.9717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BACKSTOP                MBS100",
      "code_information": [
        {
          "code": "3820086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 58.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-SURGICAL PACEDISP 5833SL",
      "code_information": [
        {
          "code": "3820163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 357,
          "minimum": 74.97,
          "maximum": 261.3954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.1861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING DISP         6651",
      "code_information": [
        {
          "code": "3820222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACEMAKER           6697",
      "code_information": [
        {
          "code": "3820223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 222.8085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING         FL-601-97",
      "code_information": [
        {
          "code": "3820226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD                  6623",
      "code_information": [
        {
          "code": "3820227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 217.2071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON WEDGE PRESSURE",
      "code_information": [
        {
          "code": "3820550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.0976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ATH-GUIDE 8F",
      "code_information": [
        {
          "code": "3821029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUIDE 6FR",
      "code_information": [
        {
          "code": "3821056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUIDE 6F",
      "code_information": [
        {
          "code": "3821057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUID 7FR",
      "code_information": [
        {
          "code": "3821245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.0199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 162,
          "minimum": 34.02,
          "maximum": 118.6164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 100.8239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.0199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOGRAM,BALLOON     6215",
      "code_information": [
        {
          "code": "3823025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION      04527-05",
      "code_information": [
        {
          "code": "3823418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 581,
          "minimum": 122.01,
          "maximum": 425.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 361.597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-COPILOT         1003331",
      "code_information": [
        {
          "code": "3823422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP    XX*RF0xx",
      "code_information": [
        {
          "code": "3823429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 260.773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE           MAP500",
      "code_information": [
        {
          "code": "3823431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 35.4751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-SAFEGUARD PRES  D82000D",
      "code_information": [
        {
          "code": "3823437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 738,
          "minimum": 154.98,
          "maximum": 540.3636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 459.3091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP 24CM   3524",
      "code_information": [
        {
          "code": "3823443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL 5FR 20CM G00972",
      "code_information": [
        {
          "code": "3823451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-STATLOCK   D684000472",
      "code_information": [
        {
          "code": "3823520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 270,
          "minimum": 56.7,
          "maximum": 197.694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 168.0399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENVELOPE-TYRX ABSORB CMRM6133",
      "code_information": [
        {
          "code": "3823584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3142.3461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAGONFLY OPTIS    C40864x",
      "code_information": [
        {
          "code": "3824115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3181,
          "minimum": 668.01,
          "maximum": 2329.1282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1979.759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION          LNQTOOL",
      "code_information": [
        {
          "code": "3824170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 514.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION  D884-00-0019-13",
      "code_information": [
        {
          "code": "3824174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 732.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION  D884-00-0019-17",
      "code_information": [
        {
          "code": "3824175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 732.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACCESSORY     518-027",
      "code_information": [
        {
          "code": "3824178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1514,
          "minimum": 317.94,
          "maximum": 1108.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 942.2682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INJECTION     ART700SYR",
      "code_information": [
        {
          "code": "3824179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 103.3134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC 17L         6056M",
      "code_information": [
        {
          "code": "3824181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD CAP           5867-3M",
      "code_information": [
        {
          "code": "3824183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 344,
          "minimum": 72.24,
          "maximum": 251.8768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 214.0953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INTELL SYR   K05-00626F",
      "code_information": [
        {
          "code": "3824184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURGIFLO 8ML          2991",
      "code_information": [
        {
          "code": "3824205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1355,
          "minimum": 284.55,
          "maximum": 992.131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 843.3113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET             6057-45",
      "code_information": [
        {
          "code": "3824219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SERVICE WRENCH       5873W",
      "code_information": [
        {
          "code": "3824221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 526,
          "minimum": 110.46,
          "maximum": 385.1372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 327.3666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PINCH-ON-TOOL         6056",
      "code_information": [
        {
          "code": "3824225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET PACEMAKER   60xx-xx",
      "code_information": [
        {
          "code": "3824226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET             6091-53",
      "code_information": [
        {
          "code": "3824228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 237.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE  23548-001",
      "code_information": [
        {
          "code": "3824246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 927,
          "minimum": 194.67,
          "maximum": 678.7494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 576.937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-THREE PORT 203BN-R",
      "code_information": [
        {
          "code": "3824285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 46.6777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MULTIPAC-4FR SHEATH   538-493P",
      "code_information": [
        {
          "code": "3824294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 259.5283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-18G BARE          78050",
      "code_information": [
        {
          "code": "3824350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1037,
          "minimum": 217.77,
          "maximum": 759.2914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 645.3977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSEPTAL BRK-1 407201",
      "code_information": [
        {
          "code": "3824358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1765,
          "minimum": 370.65,
          "maximum": 1292.333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1098.4831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSEPTAL       G02364",
      "code_information": [
        {
          "code": "3824360",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1241,
          "minimum": 260.61,
          "maximum": 908.6602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 772.3612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV FINAL    DS2C01",
      "code_information": [
        {
          "code": "3824368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.8152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER  DS2A003",
      "code_information": [
        {
          "code": "3824369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 409,
          "minimum": 85.89,
          "maximum": 299.4698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 254.5493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-D-STAT DRY CLEAR    3005",
      "code_information": [
        {
          "code": "3824415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DEFIBRILLATOR        6998",
      "code_information": [
        {
          "code": "3824426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 514.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-PIN DF-1             6996",
      "code_information": [
        {
          "code": "3824428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 217.2071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING SMARTABLATE  SAT001",
      "code_information": [
        {
          "code": "3824441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 598.0976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICROPUNCTURE     S-MAK401",
      "code_information": [
        {
          "code": "3824445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 427,
          "minimum": 89.67,
          "maximum": 312.6494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 265.752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GLIDE 6FR   RM*BF6M10MA",
      "code_information": [
        {
          "code": "3824476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 456,
          "minimum": 95.76,
          "maximum": 333.8832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 283.8007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-SAFE ALL SZS CLS-10xx.x",
      "code_information": [
        {
          "code": "3824605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INTRODUCER     CLS-250x",
      "code_information": [
        {
          "code": "3824621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 359,
          "minimum": 75.39,
          "maximum": 262.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 223.4308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J426H",
      "code_information": [
        {
          "code": "3824635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-INJECTOR 150 C853-6150",
      "code_information": [
        {
          "code": "3824642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.7686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 27\\\"    J427H",
      "code_information": [
        {
          "code": "3824649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 38.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMAX ADHESIVE MAXA",
      "code_information": [
        {
          "code": "3824663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 149.9912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-STATLOCK PSI 0684-00-'s",
      "code_information": [
        {
          "code": "3824681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 317,
          "minimum": 66.57,
          "maximum": 232.1074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 197.2913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXR35",
      "code_information": [
        {
          "code": "3824705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 68.4607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-UNIVERSAL      6232ADJ",
      "code_information": [
        {
          "code": "3824709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-UNIVERSAL      6230UNI",
      "code_information": [
        {
          "code": "3824710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-CONNECTOR PSA EX3151",
      "code_information": [
        {
          "code": "3824711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1045,
          "minimum": 219.45,
          "maximum": 765.149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 650.3766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STERILE 30CM     406500",
      "code_information": [
        {
          "code": "3824713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 89.6213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRT XSOFT 59CM 5005",
      "code_information": [
        {
          "code": "3824883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-LONG SOFT 59CM 5014",
      "code_information": [
        {
          "code": "3824884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 371.5549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-RUST            6054-58",
      "code_information": [
        {
          "code": "3824889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 198.536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CONTROL 20ML    CCS320",
      "code_information": [
        {
          "code": "3824955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 39.8317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLUID WASTE    64000936",
      "code_information": [
        {
          "code": "3824996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 185.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-FLEXTEND FIXATION    6616",
      "code_information": [
        {
          "code": "3825028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-CONTRAST        HPF480K",
      "code_information": [
        {
          "code": "3825032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 52.9014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PASSAGE HEMOSTAS  MAP112",
      "code_information": [
        {
          "code": "3825048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 123.2293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             6628",
      "code_information": [
        {
          "code": "3825085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 309.9403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-GLIDEWIRE INSERT   MAP550",
      "code_information": [
        {
          "code": "3825086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "TUBING-HIGH PRES 20\\\"   HPF200E",
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        {
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          "type": "LOCAL"
        },
        {
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          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "KIT-PEDAL MICROPUNCTURE G02972",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-PACEMAKER ALL",
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        {
          "code": "3825190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X55X32MM 608455",
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        {
          "code": "3900059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 258.3,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 765.5151,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X60X16MM 608260",
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          "code": "3900060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 6.0X60X32MM 608460",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 6.0X65X16MM 608265",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 6.0X65X32MM 608465",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 765.5151,
              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X70X16MM 608270",
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        {
          "code": "3900064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 765.5151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 6.0X70X32MM 608470",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 765.5151,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X75X16MM 608275",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 765.5151,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X75X32MM 608475",
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        {
          "code": "3900067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X80X16MM 608280",
      "code_information": [
        {
          "code": "3900068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 765.5151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X80X32MM 608480",
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        {
          "code": "3900069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 258.3,
          "maximum": 900.606,
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 6.0X85X16MM 608285",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 765.5151,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X85X32MM 608485",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X90X16MM 608290",
      "code_information": [
        {
          "code": "3900072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X90X32MM 608490",
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        {
          "code": "3900073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X95X16MM 608295",
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        {
          "code": "3900074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 765.5151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X95X32MM 608495",
      "code_information": [
        {
          "code": "3900075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC FT 6.0X20MM 608020",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC FT 6.0X30MM 608030",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC FT 6.0X35MM 608035",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC FT 6.0X45MM 608045",
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        {
          "code": "3900079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X50MM 608050",
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        {
          "code": "3900080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X55MM 608055",
      "code_information": [
        {
          "code": "3900081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X65MM 608065",
      "code_information": [
        {
          "code": "3900082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 765.5151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X75MM 608075",
      "code_information": [
        {
          "code": "3900083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X80MM 608080",
      "code_information": [
        {
          "code": "3900084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X90MM 608090",
      "code_information": [
        {
          "code": "3900085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X95MM 608095",
      "code_information": [
        {
          "code": "3900086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 1.7MM 59-17049E",
      "code_information": [
        {
          "code": "3900087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 2.3MM 59-23049E",
      "code_information": [
        {
          "code": "3900088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 2.3MM 619915",
      "code_information": [
        {
          "code": "3900089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X120MM 5079-6-120",
      "code_information": [
        {
          "code": "3900090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X150MM 5079-6-150",
      "code_information": [
        {
          "code": "3900091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X30MM 5079-6-030",
      "code_information": [
        {
          "code": "3900092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X40MM 5079-6-040",
      "code_information": [
        {
          "code": "3900093",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X50MM 5079-6-050",
      "code_information": [
        {
          "code": "3900094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X60MM 5079-6-060",
      "code_information": [
        {
          "code": "3900095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X90MM 5079-6-090",
      "code_information": [
        {
          "code": "3900096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 5X200/60TH 5018-6-200",
      "code_information": [
        {
          "code": "3900097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2X36/15TH 5065-3-615",
      "code_information": [
        {
          "code": "3900098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2X45/20TH 5065-4-520",
      "code_information": [
        {
          "code": "3900099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2X90/15TH 5065-9-015",
      "code_information": [
        {
          "code": "3900100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 225.9203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 4X90/20TH 5027-2-090",
      "code_information": [
        {
          "code": "3900102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 759,
          "minimum": 159.39,
          "maximum": 555.7398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 472.3788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 702626",
      "code_information": [
        {
          "code": "3900103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1294,
          "minimum": 271.74,
          "maximum": 947.4668,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 805.3468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.4X26MM 656126",
      "code_information": [
        {
          "code": "3900118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 807.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.4X28MM 656128",
      "code_information": [
        {
          "code": "3900119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 807.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.4X30MM 656130",
      "code_information": [
        {
          "code": "3900120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 807.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.4X32MM 656132",
      "code_information": [
        {
          "code": "3900121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 807.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.4X34MM 656134",
      "code_information": [
        {
          "code": "3900122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 807.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.4X36MM 656136",
      "code_information": [
        {
          "code": "3900123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 807.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.4X38MM 656138",
      "code_information": [
        {
          "code": "3900124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 807.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.4X8MM 656108",
      "code_information": [
        {
          "code": "3900125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          ]
        }
      ],
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          "type": "LOCAL"
        },
        {
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          "type": "RC"
        }
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            }
          ]
        }
      ],
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
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    {
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        },
        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
      ],
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        {
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          ]
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          ]
        }
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          ]
        }
      ],
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        {
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        }
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            }
          ]
        }
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        }
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        }
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        }
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        }
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        {
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          ]
        }
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        {
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        }
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        }
      ],
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    {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X40MM 656140",
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        {
          "code": "3900164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X42MM 656142",
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        {
          "code": "3900165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1252.23,
          "maximum": 4366.1086,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X44MM 656144",
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        {
          "code": "3900166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1276.59,
          "maximum": 4451.0438,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.7X65MM 656465",
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        {
          "code": "3900185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1190.7,
          "maximum": 4151.574,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE 2.7X9MM 656409",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE 1.7X13MM 662613",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X14MM 662614",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X15MM 662615",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4584.3774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X16MM 662616",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X18MM 662618",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X20MM 662620",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4202.2422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X22MM 662622",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1449.21,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1481.97,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4392.0651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X5MM 662605",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1514.31,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4487.9101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X6MM 662606",
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        {
          "code": "3900199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 1546.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4584.3774,
              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X7MM 662607",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-EMERG 2.5X6MM 663906",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 251.79,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 4.0X26MM 604626",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 366.03,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 4.0X28MM 604628",
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        {
          "code": "3900211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-ANGLE 11MM 4922-2-120",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 4.0X95MM 661095",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X14MM 661114",
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        },
        {
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          "type": "RC"
        }
      ],
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        {
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 5.0X18MM 661118",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X20MM 661120",
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        },
        {
          "code": "0270",
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        }
      ],
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X95MM 661195",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X20MM 601620",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X22MM 601622",
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        {
          "code": "3900222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X24MM 601624",
      "code_information": [
        {
          "code": "3900223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X28MM 601628",
      "code_information": [
        {
          "code": "3900224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X34MM 601634",
      "code_information": [
        {
          "code": "3900225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X36MM 601636",
      "code_information": [
        {
          "code": "3900226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X44MM 601644",
      "code_information": [
        {
          "code": "3900227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X6MM 662506",
      "code_information": [
        {
          "code": "3900239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X7MM 662507",
      "code_information": [
        {
          "code": "3900240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X9MM 662509",
      "code_information": [
        {
          "code": "3900241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X14MM 663714",
      "code_information": [
        {
          "code": "3900242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X15MM 663715",
      "code_information": [
        {
          "code": "3900243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X18MM 663718",
      "code_information": [
        {
          "code": "3900244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X20MM 663720",
      "code_information": [
        {
          "code": "3900245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X22MM 663722",
      "code_information": [
        {
          "code": "3900246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X24MM 663724",
      "code_information": [
        {
          "code": "3900247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X26MM 663726",
      "code_information": [
        {
          "code": "3900248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 625.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X30MM 656030",
      "code_information": [
        {
          "code": "3900263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X32MM 656032",
      "code_information": [
        {
          "code": "3900264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X34MM 656034",
      "code_information": [
        {
          "code": "3900265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X36MM 656036",
      "code_information": [
        {
          "code": "3900266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X38MM 656038",
      "code_information": [
        {
          "code": "3900267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X8MM 656008",
      "code_information": [
        {
          "code": "3900268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X30MM 656330",
      "code_information": [
        {
          "code": "3900269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X32MM 656332",
      "code_information": [
        {
          "code": "3900270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X34MM 656334",
      "code_information": [
        {
          "code": "3900271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X36MM 656336",
      "code_information": [
        {
          "code": "3900272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X65MM 602865",
      "code_information": [
        {
          "code": "3900286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 8.0X40MM 611040",
      "code_information": [
        {
          "code": "3900287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 8.0X45MM 611045",
      "code_information": [
        {
          "code": "3900288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 649.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 8.0X50MM 611050",
      "code_information": [
        {
          "code": "3900289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANN 8.0X55MM 611055",
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        {
          "code": "3900290",
          "type": "LOCAL"
        },
        {
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        }
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANN 8.0X60MM 611060",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANN 8.0X65MM 611065",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANN 8.0X70MM 611070",
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          "type": "LOCAL"
        },
        {
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          ]
        }
      ],
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    },
    {
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        },
        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
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          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.0X30MM 657630",
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        },
        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X32MM 657632",
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        },
        {
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        }
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.0X34MM 657634",
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          "type": "LOCAL"
        },
        {
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        }
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            }
          ]
        }
      ],
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    {
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        },
        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.0X38MM 657638",
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        },
        {
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          ]
        }
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    {
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        {
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            }
          ]
        }
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    {
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        },
        {
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        }
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          ]
        }
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    },
    {
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        },
        {
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        }
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          ]
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    {
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        {
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          ]
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    {
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        {
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        }
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            }
          ]
        }
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    {
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        {
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        }
      ],
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          ]
        }
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    {
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        {
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        }
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        {
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        {
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    {
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        {
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          ]
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    {
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        {
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        {
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    {
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        {
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        }
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          "minimum": 58.17,
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          ]
        }
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    {
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        },
        {
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        }
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        {
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          "minimum": 599.55,
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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    },
    {
      "description": "SCREW-LOCK 2.4X65MM 656065",
      "code_information": [
        {
          "code": "3900325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1776.8664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X70MM 656070",
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        {
          "code": "3900326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.4X7MM 656007",
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        {
          "code": "3900327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.4X9MM 656009",
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        {
          "code": "3900328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.7X11MM 656311",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 405.3,
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.7X13MM 656313",
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        {
          "code": "3900330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 405.3,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.7X15MM 656315",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 436.8,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1294.5296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X42MM 656342",
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        {
          "code": "3900332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X44MM 656344",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1294.5296,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X46MM 656346",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1294.5296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X48MM 656348",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1294.5296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X55MM 656355",
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        {
          "code": "3900336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 586.32,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1737.657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X60MM 656360",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X65MM 656365",
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        },
        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.7X7MM 656307",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 467.67,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.7X9MM 656309",
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        },
        {
          "code": "0270",
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        }
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1839.7257,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X18MM 657018",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    {
      "description": "SCREW-LOCK FT 2.7X22MM 657022",
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        },
        {
          "code": "0270",
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        }
      ],
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X26MM 657026",
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        },
        {
          "code": "0270",
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        }
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X34MM 657034",
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        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X38MM 657038",
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        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X40MM 657040",
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        },
        {
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            }
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    {
      "description": "SCREW-LOCK FT 2.7X42MM 657042",
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        },
        {
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            {
              "payer_name": "Anthem",
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            }
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        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X44MM 657044",
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        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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          ]
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      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X46MM 657046",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 910.56,
          "maximum": 3174.8192,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2698.5963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X48MM 657048",
      "code_information": [
        {
          "code": "3900356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2195,
          "minimum": 460.95,
          "maximum": 1607.179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1366.1021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X50MM 657050",
      "code_information": [
        {
          "code": "3900357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2077,
          "minimum": 436.17,
          "maximum": 1520.7794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1292.6625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X60MM 657060",
      "code_information": [
        {
          "code": "3900359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5318,
          "minimum": 1116.78,
          "maximum": 3893.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3309.7637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X65MM 657065",
      "code_information": [
        {
          "code": "3900360",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1116.78,
          "maximum": 3893.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3309.7637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X70MM 657070",
      "code_information": [
        {
          "code": "3900361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1116.78,
          "maximum": 3893.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3309.7637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X8MM 657008",
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        {
          "code": "3900362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1116.78,
          "maximum": 3893.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3309.7637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X65MM 657365",
      "code_information": [
        {
          "code": "3900363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5577,
          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3470.9575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X70MM 657370",
      "code_information": [
        {
          "code": "3900364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5577,
          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3470.9575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-WIRE K 2.0X200MM 705135",
      "code_information": [
        {
          "code": "3900365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5577,
          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3470.9575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEED 2.0X30MM AO 703892",
      "code_information": [
        {
          "code": "3900366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 218.4519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEED 2.6X30MM AO 703894",
      "code_information": [
        {
          "code": "3900367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-10101",
      "code_information": [
        {
          "code": "3900375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5775,
          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3594.1867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-10102",
      "code_information": [
        {
          "code": "3900376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5775,
          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3594.1867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/1.7MM 57-05210",
      "code_information": [
        {
          "code": "3900377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3594.1867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/2.3 57-10161",
      "code_information": [
        {
          "code": "3900378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3594.1867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 10H/2.3MM 57-13442",
      "code_information": [
        {
          "code": "3900379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3594.1867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/2.3MM 57-13402",
      "code_information": [
        {
          "code": "3900380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3594.1867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-13420",
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        {
          "code": "3900384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 1361.22,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4034.2023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13451",
      "code_information": [
        {
          "code": "3900388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/LT 57-10121",
      "code_information": [
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3355.819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 7H/2.3 57-10160",
      "code_information": [
        {
          "code": "3900397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6066,
          "minimum": 1273.86,
          "maximum": 4441.5252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3775.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Y 7H/2.37 57-10170",
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        {
          "code": "3900398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3355.819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 16H/1.7MM 57-05216",
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        {
          "code": "3900404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 1H/1.7MM 57-05285",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7 57-05292",
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          "type": "LOCAL"
        },
        {
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/1.7/RT 57-05282",
      "code_information": [
        {
          "code": "3900412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1273.86,
          "maximum": 4441.5252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3775.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 9H/1.7MM 57-05279",
      "code_information": [
        {
          "code": "3900413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5392,
          "minimum": 1132.32,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/2.3/LT 57-10483",
      "code_information": [
        {
          "code": "3900415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1273.86,
          "maximum": 4441.5252,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/2.3/RT 57-10482",
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        {
          "code": "3900416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1132.32,
          "maximum": 3948.0224,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3355.819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10440",
      "code_information": [
        {
          "code": "3900419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3775.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP- 6H/2.3MM 57-10407",
      "code_information": [
        {
          "code": "3900422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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          "setting": "outpatient",
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-PIN TO ROD 4960-1-020",
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        {
          "code": "3900423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 599.97,
          "maximum": 2091.8954,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-ROD TO ROD 4960-1-010",
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        {
          "code": "3900424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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          "minimum": 599.97,
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              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN 4960-2-020",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN 90° 4960-2-030",
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          "code": "3900426",
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        },
        {
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-ROD TO ROD 4960-1-060",
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          "code": "3900427",
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        },
        {
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        }
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 2011.4998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 12H/143MM",
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          "code": "3900428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/1.7MM 57-10304",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-15301",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2320.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
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    {
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        }
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            }
          ]
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        }
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            }
          ]
        }
      ],
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    },
    {
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        }
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        }
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          ]
        }
      ],
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    },
    {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        {
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        }
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            }
          ]
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    },
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        }
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        }
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            }
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            }
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        }
      ],
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    {
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      ],
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    },
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        }
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-PIN TO ROD 4922-1-020",
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        {
          "code": "0270",
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        }
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            }
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    },
    {
      "description": "PLATE-PRO 10H/2.4X66MM 629670",
      "code_information": [
        {
          "code": "3900447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2320.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 20H/2X108MM 629620",
      "code_information": [
        {
          "code": "3900448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2320.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 4H/2.4X26MM 629664",
      "code_information": [
        {
          "code": "3900449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2320.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 6H/2.4X40MM 629666",
      "code_information": [
        {
          "code": "3900450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2713.5332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 8H/2.4X53MM 629668",
      "code_information": [
        {
          "code": "3900451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2713.5332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-PIN TO ROD 4922-1-030",
      "code_information": [
        {
          "code": "3900452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2713.5332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-ROD TO ROD 4922-1-010",
      "code_information": [
        {
          "code": "3900453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2713.5332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 20H/2.4X132MM 629680",
      "code_information": [
        {
          "code": "3900454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2713.5332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-PIN 5H 4922-2-020",
      "code_information": [
        {
          "code": "3900455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3106.2487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3MM 57-10185",
      "code_information": [
        {
          "code": "3900456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3106.2487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3MM 57-13185",
      "code_information": [
        {
          "code": "3900457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3106.2487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 16H/1.7MM 57-10316",
      "code_information": [
        {
          "code": "3900458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3106.2487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2+2H/1.7 57-10397",
      "code_information": [
        {
          "code": "3900459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5623,
          "minimum": 1180.83,
          "maximum": 4117.1606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3499.5865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/1.7 57-10390",
      "code_information": [
        {
          "code": "3900460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3106.2487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/2.3 57-15390",
      "code_information": [
        {
          "code": "3900461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3106.2487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 9H/1.7MM 57-10379",
      "code_information": [
        {
          "code": "3900474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 14H/167MM",
      "code_information": [
        {
          "code": "3900475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 16H/191MM",
      "code_information": [
        {
          "code": "3900476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 10H/2X57MM 629630",
      "code_information": [
        {
          "code": "3900477",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 6H/2X34MM 629626",
      "code_information": [
        {
          "code": "3900478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 8H/2X46MM 629628",
      "code_information": [
        {
          "code": "3900479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2X23MM 629624",
      "code_information": [
        {
          "code": "3900480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 10H 629560",
      "code_information": [
        {
          "code": "3900481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 9H 629559",
      "code_information": [
        {
          "code": "3900482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 10H 629510",
      "code_information": [
        {
          "code": "3900483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 8H 629548",
      "code_information": [
        {
          "code": "3900484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR LONG LT 54-25405",
      "code_information": [
        {
          "code": "3900499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR LONG RT 54-25404",
      "code_information": [
        {
          "code": "3900500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR SHORT LT 54-25403",
      "code_information": [
        {
          "code": "3900501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR SHORT RT 54-25402",
      "code_information": [
        {
          "code": "3900502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.4X69MM 629690",
      "code_information": [
        {
          "code": "3900503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2.4X28 629684",
      "code_information": [
        {
          "code": "3900504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2.4X41MM 629686",
      "code_information": [
        {
          "code": "3900505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.4X56MM 629688",
      "code_information": [
        {
          "code": "3900506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/150MM 629512",
      "code_information": [
        {
          "code": "3900507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/174MM 629514",
      "code_information": [
        {
          "code": "3900508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 11H 629561",
      "code_information": [
        {
          "code": "3900509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 12H 629562",
      "code_information": [
        {
          "code": "3900510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 14H 629564",
      "code_information": [
        {
          "code": "3900511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.4X80 629710",
      "code_information": [
        {
          "code": "3900512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X5H/2.7X47MM 629784",
      "code_information": [
        {
          "code": "3900530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 5X10H/2.7X87MM 629787",
      "code_information": [
        {
          "code": "3900531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TRI 10H/2.4X81MM 629791",
      "code_information": [
        {
          "code": "3900532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-Y 10H/2.4X81MM 629790",
      "code_information": [
        {
          "code": "3900533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 12H/2.7X108 629752",
      "code_information": [
        {
          "code": "3900534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 227.22,
          "maximum": 792.2404,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-LOCK 14H/2.7X125 629754",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL STD LT 54-25291",
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        {
          "code": "3900536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL STD RT 54-25290",
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        {
          "code": "3900537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL WIDE LT 54-25293",
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        {
          "code": "3900538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL WIDE RT 54-25292",
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        {
          "code": "3900539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/LT 628303",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/RT 629323",
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        {
          "code": "3900541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/RT/629263",
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        {
          "code": "3900542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/84MM/LT 629203",
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        {
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        },
        {
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-HUM 3H/84MM/RT 629223",
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        },
        {
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 3H 629283",
      "code_information": [
        {
          "code": "3900545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.4043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 10H/2.7X92MM 629788",
      "code_information": [
        {
          "code": "3900546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TRI 10H/2.7X92MM 629789",
      "code_information": [
        {
          "code": "3900547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/5X79MM 627534",
      "code_information": [
        {
          "code": "3900548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DEC 6H/75MM/LT 628006",
      "code_information": [
        {
          "code": "3900549",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/105MM/LT 629244",
      "code_information": [
        {
          "code": "3900550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/109MM/LT 629204",
      "code_information": [
        {
          "code": "3900551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/109MM/RT 629204",
      "code_information": [
        {
          "code": "3900552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/LT 629304",
      "code_information": [
        {
          "code": "3900553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/RT 629324",
      "code_information": [
        {
          "code": "3900554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 862.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/128MM/RT 629266",
      "code_information": [
        {
          "code": "3900555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/132MM /RT 629226",
      "code_information": [
        {
          "code": "3900556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/132MM/LT 629206",
      "code_information": [
        {
          "code": "3900557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/LT 629306",
      "code_information": [
        {
          "code": "3900558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/RT 629326",
      "code_information": [
        {
          "code": "3900559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 4H 629284",
      "code_information": [
        {
          "code": "3900560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 6H 629286",
      "code_information": [
        {
          "code": "3900561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-OLE 6H/113MM/LT 629346",
      "code_information": [
        {
          "code": "3900562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/71MM/RT 627734",
      "code_information": [
        {
          "code": "3900563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 12H/76MM/RT 54-25385",
      "code_information": [
        {
          "code": "3900564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 14H/76MM/LT 54-25377",
      "code_information": [
        {
          "code": "3900565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 14H/76MM/RT 54-25387",
      "code_information": [
        {
          "code": "3900566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG 54-25296",
      "code_information": [
        {
          "code": "3900567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG 54-25297",
      "code_information": [
        {
          "code": "3900568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG LT 54-25295",
      "code_information": [
        {
          "code": "3900569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG RT 54-25294",
      "code_information": [
        {
          "code": "3900570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 5H/84MM/LT 627705",
      "code_information": [
        {
          "code": "3900571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 5H/84MM/RT 627735",
      "code_information": [
        {
          "code": "3900572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 5H/5X97MM 627535",
      "code_information": [
        {
          "code": "3900573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/5X115MM 627536",
      "code_information": [
        {
          "code": "3900574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/5X119MM 627566",
      "code_information": [
        {
          "code": "3900575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 6H/97MM/LT 627706",
      "code_information": [
        {
          "code": "3900576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/97MM/LT 627404",
      "code_information": [
        {
          "code": "3900577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/97MM/RT 627434",
      "code_information": [
        {
          "code": "3900578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 866.339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/123MM/LT 627708",
      "code_information": [
        {
          "code": "3900579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 6H 628406",
      "code_information": [
        {
          "code": "3900580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 7 H 628407",
      "code_information": [
        {
          "code": "3900581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 8 H 628408",
      "code_information": [
        {
          "code": "3900582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 10H 628310",
      "code_information": [
        {
          "code": "3900583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 7 H 628307",
      "code_information": [
        {
          "code": "3900584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 8 H 628308",
      "code_information": [
        {
          "code": "3900585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 10H/120MM/RT 628130",
      "code_information": [
        {
          "code": "3900586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 8H/97MM/LT 628108",
      "code_information": [
        {
          "code": "3900587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 8H/97MM/RT 628128",
      "code_information": [
        {
          "code": "3900588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 680.8728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 11H/5X209MM 627571",
      "code_information": [
        {
          "code": "3900590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1002.0157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/5X223MM 627542",
      "code_information": [
        {
          "code": "3900591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1002.0157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/5X227MM 627572",
      "code_information": [
        {
          "code": "3900592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1002.0157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 8H/5X155MM 627568",
      "code_information": [
        {
          "code": "3900593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1400.9549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 9H/5X173MM 627569",
      "code_information": [
        {
          "code": "3900594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1400.9549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/102MM RT 627484",
      "code_information": [
        {
          "code": "3900595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1400.9549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/102MM/LT 627454",
      "code_information": [
        {
          "code": "3900596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1400.9549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 13H/5X245MM 627573",
      "code_information": [
        {
          "code": "3900597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1770,
          "minimum": 371.7,
          "maximum": 1295.994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1101.5949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/5X259MM 627544",
      "code_information": [
        {
          "code": "3900598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2855,
          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1776.8664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/5X263MM 627574",
      "code_information": [
        {
          "code": "3900599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1270.8795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 6H/127MM/LT 627456",
      "code_information": [
        {
          "code": "3900600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1270.8795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/121MM/LT 627304",
      "code_information": [
        {
          "code": "3900601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1270.8795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/153MM/RT 627488",
      "code_information": [
        {
          "code": "3900602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1270.8795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/178MM/LT 627460",
      "code_information": [
        {
          "code": "3900603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1740.1465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 6H/RT 628166",
      "code_information": [
        {
          "code": "3900608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 8H/LT 628148",
      "code_information": [
        {
          "code": "3900609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 8H/RT 628168",
      "code_information": [
        {
          "code": "3900610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/199MM/LT 627310",
      "code_information": [
        {
          "code": "3900611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/199MM/RT 627340",
      "code_information": [
        {
          "code": "3900612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 12H/225MM/LT 627312",
      "code_information": [
        {
          "code": "3900613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 12H/225MM/RT 627342",
      "code_information": [
        {
          "code": "3900614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/139MM 629388",
      "code_information": [
        {
          "code": "3900615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/150MM/LT 629248",
      "code_information": [
        {
          "code": "3900616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1511.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/156MM/LT 629208",
      "code_information": [
        {
          "code": "3900617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/156MM/RT 629228",
      "code_information": [
        {
          "code": "3900618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/LT 629308",
      "code_information": [
        {
          "code": "3900619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/RT 629328",
      "code_information": [
        {
          "code": "3900620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 8H 629288",
      "code_information": [
        {
          "code": "3900621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-OLE 8H/137MM/LT 629348",
      "code_information": [
        {
          "code": "3900622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 14H/251MM/LT 627314",
      "code_information": [
        {
          "code": "3900623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 14H/251MM/RT 627344",
      "code_information": [
        {
          "code": "3900624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 7H/122/LT 628207",
      "code_information": [
        {
          "code": "3900625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 7H/122/RT 628227",
      "code_information": [
        {
          "code": "3900626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1191.8385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 10H/176MM/RT 627240",
      "code_information": [
        {
          "code": "3900627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1740.1465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/151MM/LT 627208",
      "code_information": [
        {
          "code": "3900628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1740.1465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 4H/130MM/RT 627634",
      "code_information": [
        {
          "code": "3900630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1740.1465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 14H/310MM/LT 627614",
      "code_information": [
        {
          "code": "3900636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 411,
          "minimum": 86.31,
          "maximum": 300.9342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 255.7941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 14H/310MM/RT 627644",
      "code_information": [
        {
          "code": "3900637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 411,
          "minimum": 86.31,
          "maximum": 300.9342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 255.7941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 16H/343MM/RT 627646",
      "code_information": [
        {
          "code": "3900638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 685.8517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-GAIT UNIVERSAL M2616D01",
      "code_information": [
        {
          "code": "4432470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 59.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IC SILVER 16FR 30CC SI16",
      "code_information": [
        {
          "code": "4433340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.0199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN FOLEY 12 FR 5CC",
      "code_information": [
        {
          "code": "4435701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 135.0543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENIPUNCTURE STIK-GUARD",
      "code_information": [
        {
          "code": "4445500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 54.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYMEM 3X1",
      "code_information": [
        {
          "code": "4452250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 37.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEN 4X12 1/2 5124",
      "code_information": [
        {
          "code": "4454125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 98.9568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EXT MIC-KEY 0121-24",
      "code_information": [
        {
          "code": "4455449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 94.6002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-DISP SLIPTIP DX",
      "code_information": [
        {
          "code": "4458390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 44.1883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-EBUS          MAJ-1351",
      "code_information": [
        {
          "code": "4820147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 241.4796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RAPID REFILL INJECTION",
      "code_information": [
        {
          "code": "4820306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 335,
          "minimum": 70.35,
          "maximum": 245.287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 208.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RX DELIVERY 10FR",
      "code_information": [
        {
          "code": "4820316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHOTRIPTER RX",
      "code_information": [
        {
          "code": "4820525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1065.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL PULM 0 12/120",
      "code_information": [
        {
          "code": "4820546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1671,
          "minimum": 350.91,
          "maximum": 1223.5062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1039.9803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CLEANING          000336",
      "code_information": [
        {
          "code": "4820730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 166.7952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CLEANING 1-1.5MMX1650MM",
      "code_information": [
        {
          "code": "4820735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 132,
          "minimum": 27.72,
          "maximum": 96.6504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 82.1528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY BARD     000107",
      "code_information": [
        {
          "code": "4820950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 119.495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY RX",
      "code_information": [
        {
          "code": "4821045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 677.1386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-MICRO BIOLOGY        130",
      "code_information": [
        {
          "code": "4821100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 169.2846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G TUBE ALL SIZES",
      "code_information": [
        {
          "code": "4821257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1029,
          "minimum": 216.09,
          "maximum": 753.4338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 640.4187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TAPER TIP RX      4577",
      "code_information": [
        {
          "code": "4821690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 878,
          "minimum": 184.38,
          "maximum": 642.8716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 546.4409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO PH     9012B1011",
      "code_information": [
        {
          "code": "4821720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1211.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-TWISTER PLUS 26MM",
      "code_information": [
        {
          "code": "4822220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 464.9104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTAT RESOLUTION",
      "code_information": [
        {
          "code": "4822320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 812.8152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LOCKING ERCP RX    4526",
      "code_information": [
        {
          "code": "4822475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 110.7819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP  RJ4 1333-4",
      "code_information": [
        {
          "code": "4823705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 108.9147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY SUPERTRAX",
      "code_information": [
        {
          "code": "4823755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 464.9104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW DISP 1550-40",
      "code_information": [
        {
          "code": "4823800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 275,
          "minimum": 57.75,
          "maximum": 201.355,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 171.1517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ANGIOGRAPHIC CATHETER",
      "code_information": [
        {
          "code": "4824510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 799.1231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDER-SPEED SUPERVIEW 7  4225",
      "code_information": [
        {
          "code": "4824650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1655,
          "minimum": 347.55,
          "maximum": 1211.791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1030.0223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-MULTIBITE 240 CM   1012",
      "code_information": [
        {
          "code": "4825400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 276.9547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-400Y-0423",
      "code_information": [
        {
          "code": "4825501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR   NM-400L-0525",
      "code_information": [
        {
          "code": "4825519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GAUGE EBUS",
      "code_information": [
        {
          "code": "4825530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 529.0145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GAUGE EBUS",
      "code_information": [
        {
          "code": "4825535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 715.7255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EXCELON  19G",
      "code_information": [
        {
          "code": "4825654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-NEEDLE RX F/G",
      "code_information": [
        {
          "code": "4825690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-WANG              MW319",
      "code_information": [
        {
          "code": "4825700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 580,
          "minimum": 121.8,
          "maximum": 424.676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 360.9746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTION 25GA",
      "code_information": [
        {
          "code": "4825701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 383,
          "minimum": 80.43,
          "maximum": 280.4326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 238.3677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-FOOD BOLUS ROTH   00711155",
      "code_information": [
        {
          "code": "4825703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 915,
          "minimum": 192.15,
          "maximum": 669.963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 569.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-ROTATING RETRIVAL 00711050",
      "code_information": [
        {
          "code": "4825705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 562.6225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 1.5MM 4.5FR 150CM",
      "code_information": [
        {
          "code": "4825995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 975.2538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD 7 FR           6007",
      "code_information": [
        {
          "code": "4826050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1249,
          "minimum": 262.29,
          "maximum": 914.5178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 777.3401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-CATHETER MANOSHIELD",
      "code_information": [
        {
          "code": "4826655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL STD 240CM      6232",
      "code_information": [
        {
          "code": "4827202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 125.7187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-DISP HEXAGON CAPTIVATOR",
      "code_information": [
        {
          "code": "4827315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 130.0753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-POLYP 00711099",
      "code_information": [
        {
          "code": "4828705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 170,
          "minimum": 35.7,
          "maximum": 124.474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 105.8029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLON DECOMP  CDSG-14-175",
      "code_information": [
        {
          "code": "4829170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1525,
          "minimum": 320.25,
          "maximum": 1116.605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 949.1142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 14FR 0100-14LV",
      "code_information": [
        {
          "code": "4829260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.2559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22 FR  0100-22",
      "code_information": [
        {
          "code": "4829300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 24 FR  0100-24",
      "code_information": [
        {
          "code": "4829350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 235.2559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 26 FR  0100-26",
      "code_information": [
        {
          "code": "4829400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 242.1019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10 FR 30-7361",
      "code_information": [
        {
          "code": "4829700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 268.2415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION ENDOGATOR",
      "code_information": [
        {
          "code": "4829895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 90.866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BIOPSY DISP       MAJ210",
      "code_information": [
        {
          "code": "4830135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SUCTION DISP      MAJ209",
      "code_information": [
        {
          "code": "4830150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 113.2713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-AQUAPLAST 12X18 3.2MM",
      "code_information": [
        {
          "code": "5699102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 9X12 MT-APU-12",
      "code_information": [
        {
          "code": "5750063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 242.1019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-PROBE PROSTATE   613-245",
      "code_information": [
        {
          "code": "5995267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 118.2503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BARD BIOPSY 12G     121210",
      "code_information": [
        {
          "code": "5995268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 403.9181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE ENDOCAVITY",
      "code_information": [
        {
          "code": "5995272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 253,
          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 157.4596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE ULTRA PRO II",
      "code_information": [
        {
          "code": "5995273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ULTRASOUND 12GX12CM",
      "code_information": [
        {
          "code": "5995304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 1044.3369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY ALL SZS",
      "code_information": [
        {
          "code": "5995532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 514,
          "minimum": 107.94,
          "maximum": 376.3508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 319.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY 14X10",
      "code_information": [
        {
          "code": "5995534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 545,
          "minimum": 114.45,
          "maximum": 399.049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 339.1916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 14GAX15C",
      "code_information": [
        {
          "code": "5995547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 457,
          "minimum": 95.97,
          "maximum": 334.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 284.4231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 14GAX11C",
      "code_information": [
        {
          "code": "5995550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 416,
          "minimum": 87.36,
          "maximum": 304.5952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 258.9059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-H/S PROCEDURE     61-5205",
      "code_information": [
        {
          "code": "5995761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 584,
          "minimum": 122.64,
          "maximum": 427.6048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 363.4641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SERTERA-12GA CORE DEVICE",
      "code_information": [
        {
          "code": "5995763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SERTERA-14GA CORE DEVICE",
      "code_information": [
        {
          "code": "5995764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 520.3013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENCOR BX SCCAN01",
      "code_information": [
        {
          "code": "7295114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 96.4673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC&RINSE TUBE DS4001",
      "code_information": [
        {
          "code": "7295115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 312.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-ENCOR NEEDLE 7G",
      "code_information": [
        {
          "code": "7295267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 84.6423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRI SCALPEL/NEEDLE KIT",
      "code_information": [
        {
          "code": "7295418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 194.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-HS TMI1156",
      "code_information": [
        {
          "code": "7295727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 61.6146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE F/MRI SSQK65/115VS",
      "code_information": [
        {
          "code": "7295730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 148.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-COAXIAL BIPSY 946x-VC-006",
      "code_information": [
        {
          "code": "1416380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OPTIFIX-ABSORBABLE 0113126",
      "code_information": [
        {
          "code": "3000012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 7.3     310.495",
      "code_information": [
        {
          "code": "3002265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT LARYNGEAL 4MM",
      "code_information": [
        {
          "code": "3003289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OXFORD SAW 506298",
      "code_information": [
        {
          "code": "3003294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-TUR PK           786500",
      "code_information": [
        {
          "code": "3003816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 96370-023",
      "code_information": [
        {
          "code": "3004233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-020",
      "code_information": [
        {
          "code": "3008516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 11X280       357.404",
      "code_information": [
        {
          "code": "3012311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX     2274-25-500",
      "code_information": [
        {
          "code": "3012384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 7.0X3.2",
      "code_information": [
        {
          "code": "3012900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-HALO CUTTING HACF-0533",
      "code_information": [
        {
          "code": "3013285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EVICEL FIBRIN SEALANT 3905",
      "code_information": [
        {
          "code": "3021100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-SEALER 5MM     LF1637",
      "code_information": [
        {
          "code": "3021738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-TUR       784415 & 784515",
      "code_information": [
        {
          "code": "3021867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3021877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
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    {
      "description": "NEEDLE-NAVIGATED PAK9733498NAV",
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    {
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    {
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    {
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    {
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    {
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      "service_type": "CDM"
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    {
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        {
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        {
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      "service_type": "CDM"
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    {
      "description": "SHEAR-HARMONIC LAP 45\\\" HARH45",
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          "code": "0270",
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    {
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      "service_type": "CDM"
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    {
      "description": "REAMER-CONCAVE 018 XFR004118",
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        }
      ],
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    {
      "description": "REAMER-CONVEX 018 XFR004218",
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          ]
        }
      ],
      "service_type": "CDM"
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    {
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    {
      "description": "SEALER-MARYLAND OPEN LF1937",
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    {
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      ],
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    {
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        {
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-UNIV SONIC 5450815114",
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        {
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      ],
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        {
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-VENTRIC PACING    D98100",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.915S",
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        {
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      ],
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        {
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              "methodology": "percent of total billed charges",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-7.0 CANNULATED 400146",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSSEPTAL RF",
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        {
          "code": "0270",
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        }
      ],
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        {
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        }
      ],
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    },
    {
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 10MM 03.037.021",
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      ],
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        {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 550 AC-10030120",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRING 675.705S",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-8\\\" INSULATED 675.706S",
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        },
        {
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 698.605S",
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          "type": "LOCAL"
        },
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER/SHAVER-ALL",
      "code_information": [
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          "code": "3550238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HAMMER-SLAP 694.008",
      "code_information": [
        {
          "code": "3550243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-DIRECT MEASURE 702495",
      "code_information": [
        {
          "code": "3550617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-HELIX 6.5 ADVANCE 222313",
      "code_information": [
        {
          "code": "3550751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.7X160 A-8004.01",
      "code_information": [
        {
          "code": "3550825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DRIVER 4 CANN A-8004.11",
      "code_information": [
        {
          "code": "3550827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-LIGASURE 37CM LF1944",
      "code_information": [
        {
          "code": "3559070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 16MM XFR004216",
      "code_information": [
        {
          "code": "3559091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-WIRELESS CELL EX1151",
      "code_information": [
        {
          "code": "3559233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-15MM/3.5OS 9159.3035",
      "code_information": [
        {
          "code": "3559597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 2.0",
      "code_information": [
        {
          "code": "3559670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3566817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40B GCS40B",
      "code_information": [
        {
          "code": "3598106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM 03.333.103",
      "code_information": [
        {
          "code": "3598147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-STRT TIP BAYON 1590-01",
      "code_information": [
        {
          "code": "3598218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH",
      "code_information": [
        {
          "code": "3598452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SUREFORM 60 480460",
      "code_information": [
        {
          "code": "3598611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 27CM APYX-27-TP",
      "code_information": [
        {
          "code": "3598956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-1X10.5MM BI 632.678S",
      "code_information": [
        {
          "code": "3599051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERCLAGE AR-7268",
      "code_information": [
        {
          "code": "3599170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-CERCLAGE AR-7268T",
      "code_information": [
        {
          "code": "3599171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM 03.333.102",
      "code_information": [
        {
          "code": "3599533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-NANO 125MM AR-3210-0043",
      "code_information": [
        {
          "code": "3600299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-MINI COREDX M00515220",
      "code_information": [
        {
          "code": "3600762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR CVD GCS40G",
      "code_information": [
        {
          "code": "3600838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-LARGE DV2012-LF",
      "code_information": [
        {
          "code": "3600953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-8-13MM P99-110-0813",
      "code_information": [
        {
          "code": "3601104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-UNIVERSAL PAD ARTICGEL",
      "code_information": [
        {
          "code": "3601634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIBER OPTIC PTEYE-1",
      "code_information": [
        {
          "code": "3602127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE 45\\\" HAR745",
      "code_information": [
        {
          "code": "3602909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE HAR736",
      "code_information": [
        {
          "code": "3602910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA 13CM PRE1101US",
      "code_information": [
        {
          "code": "3603187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 11G NN-1000",
      "code_information": [
        {
          "code": "3603528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 13G NN-1001",
      "code_information": [
        {
          "code": "3603586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY MAX M00546470",
      "code_information": [
        {
          "code": "3603811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL M00546550",
      "code_information": [
        {
          "code": "3603812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-RETRIEVAL M00546560",
      "code_information": [
        {
          "code": "3603813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-8MM/CV SF30 488530",
      "code_information": [
        {
          "code": "3603862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY 115CM G48240",
      "code_information": [
        {
          "code": "3603969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 25 LS96555-025",
      "code_information": [
        {
          "code": "3604574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SUPERLOOP TUR 784415",
      "code_information": [
        {
          "code": "3604601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-AO T8 93MM 542011",
      "code_information": [
        {
          "code": "3604892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-SD T20 93MM 542066",
      "code_information": [
        {
          "code": "3604973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BG 6MM ABS-8000-06",
      "code_information": [
        {
          "code": "3605017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-3 SYS REFERENCE   CREFP6",
      "code_information": [
        {
          "code": "3824414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X6MM 656306",
      "code_information": [
        {
          "code": "3900339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X70MM 656370",
      "code_information": [
        {
          "code": "3900340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/178MM/RT 627490",
      "code_information": [
        {
          "code": "3900604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/173MM/RT 627338",
      "code_information": [
        {
          "code": "3900605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DEC BRIDGE 8H/RT 628068",
      "code_information": [
        {
          "code": "3900606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 6H/LT 628146",
      "code_information": [
        {
          "code": "3900607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/151MM/RT 627238",
      "code_information": [
        {
          "code": "3900629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 6H/166MM/LT 627606",
      "code_information": [
        {
          "code": "3900631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 6H/166MM/RT 627636",
      "code_information": [
        {
          "code": "3900632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 12H/202MM/RT 627242",
      "code_information": [
        {
          "code": "3900633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 8H/202MM/LT 627608",
      "code_information": [
        {
          "code": "3900634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 12H/274MM/RT 627642",
      "code_information": [
        {
          "code": "3900635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAM SB3",
      "code_information": [
        {
          "code": "4821711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 2088.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE    16G X 12.5",
      "code_information": [
        {
          "code": "1410723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANTENNA-PROGRAMMER       37092",
      "code_information": [
        {
          "code": "3000651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        310.111",
      "code_information": [
        {
          "code": "3002241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2       AR-8944-22",
      "code_information": [
        {
          "code": "3002251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0          316.396",
      "code_information": [
        {
          "code": "3002271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM         310.31",
      "code_information": [
        {
          "code": "3002300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM         310.11",
      "code_information": [
        {
          "code": "3002784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM         310.26",
      "code_information": [
        {
          "code": "3002788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM         310.44",
      "code_information": [
        {
          "code": "3002798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DISSECT ELECTRODE 139330",
      "code_information": [
        {
          "code": "3002955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW             511.9xxS",
      "code_information": [
        {
          "code": "3003266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS  03.000.3xxS",
      "code_information": [
        {
          "code": "3003268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 532.066S",
      "code_information": [
        {
          "code": "3003293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 225 ML04253",
      "code_information": [
        {
          "code": "3003420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 125ML 04251",
      "code_information": [
        {
          "code": "3003421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 4MM PAL-404LLB",
      "code_information": [
        {
          "code": "3004044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-304LLB",
      "code_information": [
        {
          "code": "3004046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO PAL-304LM",
      "code_information": [
        {
          "code": "3004053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPORT II PAL-406LS",
      "code_information": [
        {
          "code": "3004250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHOLANGIOGRAM       C100",
      "code_information": [
        {
          "code": "3005220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR TITANIUM  FV012T",
      "code_information": [
        {
          "code": "3009771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3          316.402",
      "code_information": [
        {
          "code": "3012305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM AR-4160-35",
      "code_information": [
        {
          "code": "3012347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.141",
      "code_information": [
        {
          "code": "3012354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 310.25",
      "code_information": [
        {
          "code": "3012405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-558",
      "code_information": [
        {
          "code": "3012475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 3.2X300MM",
      "code_information": [
        {
          "code": "3014238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUGE 03.804.5x",
      "code_information": [
        {
          "code": "3020805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PREP     546102000",
      "code_information": [
        {
          "code": "3020926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 24FR      880-213",
      "code_information": [
        {
          "code": "3021819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE WATER",
      "code_information": [
        {
          "code": "3023171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE  2839-xx-xxx",
      "code_information": [
        {
          "code": "3027302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTROSURG 134006",
      "code_information": [
        {
          "code": "3029511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-TRIMANO BEACH CHAIR",
      "code_information": [
        {
          "code": "3034325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL  1.5MM W/8.0MM STOP",
      "code_information": [
        {
          "code": "3058520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM CALIBRATED",
      "code_information": [
        {
          "code": "3058937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 19 G05880",
      "code_information": [
        {
          "code": "3058996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8943-",
      "code_information": [
        {
          "code": "3059000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-AIRWAY EXCH 8F G07833",
      "code_information": [
        {
          "code": "3059157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 11 G06732",
      "code_information": [
        {
          "code": "3059264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-4.5MM INCISOR PLUS",
      "code_information": [
        {
          "code": "3060481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 5MM          CB5LT",
      "code_information": [
        {
          "code": "3079768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DOYLE II AIRWY 15-24055",
      "code_information": [
        {
          "code": "3080045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-                TLC-55",
      "code_information": [
        {
          "code": "3081528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30GRN     TX30G",
      "code_information": [
        {
          "code": "3081555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30BL      TX30B",
      "code_information": [
        {
          "code": "3081557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-8916-14",
      "code_information": [
        {
          "code": "3087940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CALIBRATED DRILL 2.5",
      "code_information": [
        {
          "code": "3087942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER   60-6085-20x",
      "code_information": [
        {
          "code": "3145100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER     G3640x",
      "code_information": [
        {
          "code": "3509540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3521005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BACK TABLE     DYNJ31777A",
      "code_information": [
        {
          "code": "3526152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-C-SECTION      DYNJ31780C",
      "code_information": [
        {
          "code": "3526153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VASCULAR LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3526426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSDUCER TRUWAVE PX272",
      "code_information": [
        {
          "code": "3526526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE UNTHREAD 2X200MM",
      "code_information": [
        {
          "code": "3526988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 16/18 FR 96551",
      "code_information": [
        {
          "code": "3527178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET",
      "code_information": [
        {
          "code": "3527263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SOMA ADULT SAFB-SM/USA",
      "code_information": [
        {
          "code": "3527866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DELIVERY NAVIFLEX 7FR.",
      "code_information": [
        {
          "code": "3527884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EPG CONNECTOR 53912D",
      "code_information": [
        {
          "code": "3549025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLOWSAFE II",
      "code_information": [
        {
          "code": "3549715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-NAIL 1806-1406S",
      "code_information": [
        {
          "code": "3549850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VORTRAN RESUSCITATION",
      "code_information": [
        {
          "code": "3550702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2020-00-335",
      "code_information": [
        {
          "code": "3550711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-DRILLING COMP EL-DTS",
      "code_information": [
        {
          "code": "3550764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SPEED FEMORAL AE-1605",
      "code_information": [
        {
          "code": "3550845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SELECTOR-VEIN 57538CSV-WOR",
      "code_information": [
        {
          "code": "3559121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-INSTRUMENT 0306-531-000",
      "code_information": [
        {
          "code": "3559266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-EXCELSIUS ARM 6143.2001S",
      "code_information": [
        {
          "code": "3559497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-MONITOR 6143.2003S",
      "code_information": [
        {
          "code": "3559498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-TRANSFUSION EXCHANGE",
      "code_information": [
        {
          "code": "3571501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR CARE XL MULTI-USE",
      "code_information": [
        {
          "code": "3598079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/KNEE WRAP",
      "code_information": [
        {
          "code": "3598180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/SHOULDER WRAP",
      "code_information": [
        {
          "code": "3598181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 94725",
      "code_information": [
        {
          "code": "3598197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE MIXTURE",
      "code_information": [
        {
          "code": "3598303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTYCORE 16GX7.5CM",
      "code_information": [
        {
          "code": "3598364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELBOW TRIMANO AR-1646",
      "code_information": [
        {
          "code": "3598377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN 1.7/2.0 DRILL 45-20011",
      "code_information": [
        {
          "code": "3598514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 10ML GIS-59",
      "code_information": [
        {
          "code": "3599411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.1X150MM 03.333.001",
      "code_information": [
        {
          "code": "3599532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPAP BUBBLE MR290 CHAMBER",
      "code_information": [
        {
          "code": "3599616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.5X150MM QC 03.133.109",
      "code_information": [
        {
          "code": "3599727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-90° SAG 2296-003-109S2",
      "code_information": [
        {
          "code": "3599964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3600835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 16H 76-9103",
      "code_information": [
        {
          "code": "3600836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 24H 76-9104",
      "code_information": [
        {
          "code": "3600837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB NTHRD AR-18800-11",
      "code_information": [
        {
          "code": "3600896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE STER 03.804.519S",
      "code_information": [
        {
          "code": "3600903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G ACCESS 03.804.517S",
      "code_information": [
        {
          "code": "3600911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X330 S0100-000",
      "code_information": [
        {
          "code": "3601632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FISTULA FUNNEL",
      "code_information": [
        {
          "code": "3601648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE BVT 03.804.520S",
      "code_information": [
        {
          "code": "3601878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE RUNTHRU 180 25-5211",
      "code_information": [
        {
          "code": "3601952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE ARTERIAL ART356",
      "code_information": [
        {
          "code": "3602029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION PD-IT",
      "code_information": [
        {
          "code": "3602078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OIL-BIENAIR LUBRIFLUID 1600064",
      "code_information": [
        {
          "code": "3602105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE 16G X 16.5",
      "code_information": [
        {
          "code": "3602125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300S NTHRD 702463S",
      "code_information": [
        {
          "code": "3602409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL",
      "code_information": [
        {
          "code": "3602464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREDED AR-18800-11T",
      "code_information": [
        {
          "code": "3602495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-5 MREYE G36405",
      "code_information": [
        {
          "code": "3602688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-3 MREYE G42419",
      "code_information": [
        {
          "code": "3602689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3602820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G BVL 0306-331-000",
      "code_information": [
        {
          "code": "3603302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE -.9MM AR-7524C",
      "code_information": [
        {
          "code": "3604464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DBL 4X30/10 PAL-405LL",
      "code_information": [
        {
          "code": "3604617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-8x30/8 PAL-402LL",
      "code_information": [
        {
          "code": "3604619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GLIDESHEATH RM*ES6J10HAT",
      "code_information": [
        {
          "code": "3824107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CATH LAB ANGIO DYNJ31773F",
      "code_information": [
        {
          "code": "3825012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X55MM 657055",
      "code_information": [
        {
          "code": "3900358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION RX  M00566670",
      "code_information": [
        {
          "code": "4822473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 557.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-VASCULAR 6MM X 7MM X 5FR",
      "code_information": [
        {
          "code": "1415480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-ANASTOCLIP LARGE 15CM",
      "code_information": [
        {
          "code": "3000773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-PASSER            8591-38",
      "code_information": [
        {
          "code": "3006601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE TISSUE REMOVAL",
      "code_information": [
        {
          "code": "3010310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED ASNIS III",
      "code_information": [
        {
          "code": "3012111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.5MM  702450",
      "code_information": [
        {
          "code": "3012114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST ASNIS III 6.5MM",
      "code_information": [
        {
          "code": "3012151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-HELI-FX            SG-64",
      "code_information": [
        {
          "code": "3016110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE EMG 8050015",
      "code_information": [
        {
          "code": "3022950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAK-CONFIDENCE PLUS",
      "code_information": [
        {
          "code": "3029292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARTHREX ANGEL BMC",
      "code_information": [
        {
          "code": "3058674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 8MMX24CM",
      "code_information": [
        {
          "code": "3058757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 6MMX17CM",
      "code_information": [
        {
          "code": "3058758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 4MMX7CM",
      "code_information": [
        {
          "code": "3058776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MM X xCM",
      "code_information": [
        {
          "code": "3058777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 6MM X xxCM",
      "code_information": [
        {
          "code": "3058840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 CX ALL",
      "code_information": [
        {
          "code": "3058847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MMX15CM",
      "code_information": [
        {
          "code": "3058884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-VERTEX DRILL 2.4MM",
      "code_information": [
        {
          "code": "3059197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-CAROTID ALL     2000-00s",
      "code_information": [
        {
          "code": "3079680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-INTERNAL EEA   EEAXL25",
      "code_information": [
        {
          "code": "3081425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-TVT DEVICE .5\\\"X18\\\" 810041",
      "code_information": [
        {
          "code": "3083229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EMBLEM TUNNELING 4711",
      "code_information": [
        {
          "code": "3084601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-PROGEL PGPS002",
      "code_information": [
        {
          "code": "3091508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER XPEEDA AC-1000729",
      "code_information": [
        {
          "code": "3526375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSSEPTAL NTK-711-8545",
      "code_information": [
        {
          "code": "3527245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 03.033.004",
      "code_information": [
        {
          "code": "3527874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-APEX 11CM 5500-25B-114",
      "code_information": [
        {
          "code": "3527983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-FEMORAL AUG SZ6 154906002",
      "code_information": [
        {
          "code": "3549097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-SPIN ACCESS INS-5900",
      "code_information": [
        {
          "code": "3550000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-INSERTER",
      "code_information": [
        {
          "code": "3550237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-VASC 14X7MM SBT1402D",
      "code_information": [
        {
          "code": "3550693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER ELEVATE 8340155",
      "code_information": [
        {
          "code": "3559412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8013090",
      "code_information": [
        {
          "code": "3559559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-9WX7L AR-8717-0907",
      "code_information": [
        {
          "code": "3598104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER SM 4934-8-100",
      "code_information": [
        {
          "code": "3600215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7FR 4",
      "code_information": [
        {
          "code": "3600789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7F 34",
      "code_information": [
        {
          "code": "3600790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX 45MM 227445500",
      "code_information": [
        {
          "code": "3600946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PREP 4.2MM 0909-100-042",
      "code_information": [
        {
          "code": "3601029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EXP 4.2MM 0909-200-042",
      "code_information": [
        {
          "code": "3601030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-16 HLW 03.037.004S",
      "code_information": [
        {
          "code": "3601121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER MD 4934-8-140",
      "code_information": [
        {
          "code": "3601242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOCLOT EPK2303-01",
      "code_information": [
        {
          "code": "3601392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AUX CBL PLT 94-1500-04-S",
      "code_information": [
        {
          "code": "3601589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-DEBRIDEMENT DDBK02",
      "code_information": [
        {
          "code": "3601755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-GUIDE VDR 80-0049",
      "code_information": [
        {
          "code": "3602651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-DELIVERY STRBL-14F-075",
      "code_information": [
        {
          "code": "3603178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AO CONN P65-001-0001-SK",
      "code_information": [
        {
          "code": "3603438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM RC P01-DWL-0915",
      "code_information": [
        {
          "code": "3604386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7.5FR",
      "code_information": [
        {
          "code": "3827764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBEROPTIC BALLOON 8.0FR",
      "code_information": [
        {
          "code": "3827765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X34MM 657734",
      "code_information": [
        {
          "code": "3900153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X36MM 657736",
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        {
          "code": "3900154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 4130.3402,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X38MM 657738",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X9MM 657709",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X11MM 656111",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE 2.4X46MM 656146",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE 2.4X48MM 656148",
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        {
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        },
        {
          "code": "0270",
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        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE 2.4X50MM 656150",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 3510.7892,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X65MM 656165",
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        },
        {
          "code": "0270",
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        }
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X6MM 656106",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3510.7892,
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            }
          ]
        }
      ],
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    },
    {
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X9MM 656109",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.7X11MM 656411",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE 2.7X13MM 656413",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.7X42MM 656442",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.7X44MM 656444",
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        },
        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
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        {
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        }
      ],
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            }
          ]
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        }
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            }
          ]
        }
      ],
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    },
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        },
        {
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        }
      ],
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          ]
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    },
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        },
        {
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        }
      ],
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        {
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            }
          ]
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      ],
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    },
    {
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        },
        {
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        }
      ],
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        {
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          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE 1.7X8MM 662608",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-EMERG 1.9X10MM 662710",
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          "code": "3900202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-EMERG 1.9X12MM 662712",
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          "code": "3900203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-EMERG 1.9X15MM 662705",
      "code_information": [
        {
          "code": "3900204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-EMERG 1.9X8MM 662708",
      "code_information": [
        {
          "code": "3900205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X22MM 663822",
      "code_information": [
        {
          "code": "3900206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X24MM 663824",
      "code_information": [
        {
          "code": "3900207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X26MM 663826",
      "code_information": [
        {
          "code": "3900208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/1.7MM 57-05202",
      "code_information": [
        {
          "code": "3900368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/LT 57-05221",
      "code_information": [
        {
          "code": "3900369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/RT 57-05220",
      "code_information": [
        {
          "code": "3900370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 6H/1.7MM 57-05240",
      "code_information": [
        {
          "code": "3900371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 10H/1.7 57-05262",
      "code_information": [
        {
          "code": "3900372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 7H/1.7MM 57-05260",
      "code_information": [
        {
          "code": "3900373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Y 7H/1.7MM 57-05270",
      "code_information": [
        {
          "code": "3900374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 5H/2.3MM 57-13405",
      "code_information": [
        {
          "code": "3900381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/2.3MM 57-13408",
      "code_information": [
        {
          "code": "3900382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 8H/2.3MM 57-13410",
      "code_information": [
        {
          "code": "3900383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-13421",
      "code_information": [
        {
          "code": "3900385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13440",
      "code_information": [
        {
          "code": "3900386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13450",
      "code_information": [
        {
          "code": "3900387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13906",
      "code_information": [
        {
          "code": "3900389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 2H/23MM 626672",
      "code_information": [
        {
          "code": "3900390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 3H/35MM",
      "code_information": [
        {
          "code": "3900391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 8.0MM LG AO",
      "code_information": [
        {
          "code": "3900392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/2.3 57-10190",
      "code_information": [
        {
          "code": "3900393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/RT 57-10120",
      "code_information": [
        {
          "code": "3900395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3MM 57-10140",
      "code_information": [
        {
          "code": "3900396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-SCREW F/ 2.7MM AO 703899",
      "code_information": [
        {
          "code": "3900399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-SCREW F/ 3.5MM AO 703898",
      "code_information": [
        {
          "code": "3900400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 4H/47MM",
      "code_information": [
        {
          "code": "3900401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 4H 629504",
      "code_information": [
        {
          "code": "3900402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 4H 629544",
      "code_information": [
        {
          "code": "3900403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2+2H/1.7 57-05297",
      "code_information": [
        {
          "code": "3900406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/1.7 57-052920",
      "code_information": [
        {
          "code": "3900407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7 57-05295",
      "code_information": [
        {
          "code": "3900410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/1.7/LT 57-05283",
      "code_information": [
        {
          "code": "3900411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/2.3MM 57-10402",
      "code_information": [
        {
          "code": "3900414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-10420",
      "code_information": [
        {
          "code": "3900417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10421",
      "code_information": [
        {
          "code": "3900418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10460",
      "code_information": [
        {
          "code": "3900420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP Y 6H/2.3MM 57-10470",
      "code_information": [
        {
          "code": "3900421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 3510.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-TOUHY BORST W/SIDE ARM",
      "code_information": [
        {
          "code": "1410050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-FEMORAL ANGIO  DYNJP4119",
      "code_information": [
        {
          "code": "1410800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18GX10CM   G01559",
      "code_information": [
        {
          "code": "1410916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-15      G03955",
      "code_information": [
        {
          "code": "1410919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CLOSED NEEDLE  LNGC-2022",
      "code_information": [
        {
          "code": "1495266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 9G EVIVA",
      "code_information": [
        {
          "code": "1495267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SWIVEL PORTEX 625191",
      "code_information": [
        {
          "code": "3002219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT ANT- 1012S",
      "code_information": [
        {
          "code": "3004017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-RANEY SCALP ADULT 20-1037",
      "code_information": [
        {
          "code": "3008833",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE       PMI-TC-SG",
      "code_information": [
        {
          "code": "3010072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE FUZZY       FZ624",
      "code_information": [
        {
          "code": "3020107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LID-COLLECTION DISP    BKC-506",
      "code_information": [
        {
          "code": "3021629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SURGISAFE ABSORB WHITE",
      "code_information": [
        {
          "code": "3029216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-UNIVRSL I AURO DYNJP1050A",
      "code_information": [
        {
          "code": "3029269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 10CM    70890856",
      "code_information": [
        {
          "code": "3029291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-STENT 6FR M0061802011",
      "code_information": [
        {
          "code": "3038668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR MANIFOLD",
      "code_information": [
        {
          "code": "3050023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 CX21D",
      "code_information": [
        {
          "code": "3058821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TRU               2C4041",
      "code_information": [
        {
          "code": "3079241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY METER ALL P4PxxULD",
      "code_information": [
        {
          "code": "3084872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COAG SUCTION      050-005",
      "code_information": [
        {
          "code": "3085551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ELECTROSURGICAL 8\\\"050-010",
      "code_information": [
        {
          "code": "3085595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX OUTFLOW AQL-111",
      "code_information": [
        {
          "code": "3086104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-3/8\\\"X3/32\\\"X8'     3508S",
      "code_information": [
        {
          "code": "3086137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8702H",
      "code_information": [
        {
          "code": "3089122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          JJ31G",
      "code_information": [
        {
          "code": "3089143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C016D",
      "code_information": [
        {
          "code": "3089188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 6-0          1732G",
      "code_information": [
        {
          "code": "3089203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX41",
      "code_information": [
        {
          "code": "3089216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J840D",
      "code_information": [
        {
          "code": "3089388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 CX22D",
      "code_information": [
        {
          "code": "3089700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-AERO          58-79510",
      "code_information": [
        {
          "code": "3284351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHARMBER-HEATER MR290",
      "code_information": [
        {
          "code": "3290069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ENDO TUBE ANCHORFAST",
      "code_information": [
        {
          "code": "3290137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ9 8.5CM",
      "code_information": [
        {
          "code": "3311077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PULLEY-OVERDOOR LUM101P",
      "code_information": [
        {
          "code": "3311351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-DERMABOND MINI",
      "code_information": [
        {
          "code": "3500037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SPIKE PRIMING   101593",
      "code_information": [
        {
          "code": "3500089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-HYPERINFLATION   1/2 LITER",
      "code_information": [
        {
          "code": "3501291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CAPNOLINE 11996-000163",
      "code_information": [
        {
          "code": "3501717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT TALL LF/ALUM 7704",
      "code_information": [
        {
          "code": "3511782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHANNEL ALL JP22xx",
      "code_information": [
        {
          "code": "3512580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 F/PEDS PEDICAP6",
      "code_information": [
        {
          "code": "3512772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LTA MADGIC       MAD600",
      "code_information": [
        {
          "code": "3512793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL LRG     L-35MM",
      "code_information": [
        {
          "code": "3513122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3514273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEEDER-SPECIALNEEDS 80ML 6000S",
      "code_information": [
        {
          "code": "3515912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLD MIC 40M SQ40SK",
      "code_information": [
        {
          "code": "3516131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE ALL SZS     N7s",
      "code_information": [
        {
          "code": "3519400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-KNEE 22\\\"   1220917",
      "code_information": [
        {
          "code": "3519967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7089-0844",
      "code_information": [
        {
          "code": "3526221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 J864D",
      "code_information": [
        {
          "code": "3526246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 8X18",
      "code_information": [
        {
          "code": "3526255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP839D",
      "code_information": [
        {
          "code": "3526344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP838",
      "code_information": [
        {
          "code": "3526348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTOR-ADULT INTUBATED AIRWAY",
      "code_information": [
        {
          "code": "3526527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GROMMET-BEVELED VENT 70241350",
      "code_information": [
        {
          "code": "3527288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS INF-L",
      "code_information": [
        {
          "code": "3541326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS NEO-L",
      "code_information": [
        {
          "code": "3541327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DELIVER MORGAN LENS MT202",
      "code_information": [
        {
          "code": "3541942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD/IV FLUID WARMER L-70",
      "code_information": [
        {
          "code": "3542396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM PREMIE N4901",
      "code_information": [
        {
          "code": "3549181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 24 JP-2234",
      "code_information": [
        {
          "code": "3549296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOCKS-TISSUE FLT-010",
      "code_information": [
        {
          "code": "3549777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIRROR-INSPECTION DIABETIC 081",
      "code_information": [
        {
          "code": "3550157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM INFANT N4902",
      "code_information": [
        {
          "code": "3550255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET NEO/INF",
      "code_information": [
        {
          "code": "3550277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVES-SKIL-CARE GERI SM 5669",
      "code_information": [
        {
          "code": "3550329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH MALE EXTERNAL MECSB01",
      "code_information": [
        {
          "code": "3550510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF LG MDS601LD",
      "code_information": [
        {
          "code": "3550554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE,MERSILINE 4-0 S-2 1779G",
      "code_information": [
        {
          "code": "3550847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT ANES 2L 72\\\"",
      "code_information": [
        {
          "code": "3559130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 S-14",
      "code_information": [
        {
          "code": "3559177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP774D",
      "code_information": [
        {
          "code": "3559182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-UNDER NOSE",
      "code_information": [
        {
          "code": "3559270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2350H",
      "code_information": [
        {
          "code": "3559280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 15 JP-2228",
      "code_information": [
        {
          "code": "3559392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 19 JP-2230",
      "code_information": [
        {
          "code": "3559393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-HUMIDIFER MR290V",
      "code_information": [
        {
          "code": "3559432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET NEO",
      "code_information": [
        {
          "code": "3559609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         C-017-D",
      "code_information": [
        {
          "code": "3560077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4258705",
      "code_information": [
        {
          "code": "3568756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-COBAN 2LAYER         2094",
      "code_information": [
        {
          "code": "3575850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND UNIVERSAL RT/LT LG",
      "code_information": [
        {
          "code": "3580012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIV 9006-00",
      "code_information": [
        {
          "code": "3580022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3598026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MAC",
      "code_information": [
        {
          "code": "3598027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LAPAROSCOPIC STR 2190J",
      "code_information": [
        {
          "code": "3598116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-POLY OVAL SOFT WIRE",
      "code_information": [
        {
          "code": "3598262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ARTHROGRAM DYNJ07425",
      "code_information": [
        {
          "code": "3598354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 1 VCP741D",
      "code_information": [
        {
          "code": "3598416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NERVE BLOCK 22G HN3S-80",
      "code_information": [
        {
          "code": "3598440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAG-DISP SUCT 10’ 30-5201",
      "code_information": [
        {
          "code": "3598648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1 VASC1346",
      "code_information": [
        {
          "code": "3598865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/63-74\\\" 1146PP",
      "code_information": [
        {
          "code": "3598976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-NASAL VIP1137380",
      "code_information": [
        {
          "code": "3599139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-NASAL VIP1137381",
      "code_information": [
        {
          "code": "3599142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE RENOVARP GIS-29",
      "code_information": [
        {
          "code": "3599229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 17-22CM",
      "code_information": [
        {
          "code": "3599603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 22-25CM",
      "code_information": [
        {
          "code": "3599604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 25-29CM",
      "code_information": [
        {
          "code": "3599605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 29-36CM",
      "code_information": [
        {
          "code": "3599606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 240014",
      "code_information": [
        {
          "code": "3599773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SSL",
      "code_information": [
        {
          "code": "3600225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1MSL",
      "code_information": [
        {
          "code": "3600226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1LSL",
      "code_information": [
        {
          "code": "3600227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL WIDE EVO1WSL",
      "code_information": [
        {
          "code": "3600228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2SSL",
      "code_information": [
        {
          "code": "3600230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2MSL",
      "code_information": [
        {
          "code": "3600231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2LSL",
      "code_information": [
        {
          "code": "3600232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CN 10MM HEX P45-940-0001",
      "code_information": [
        {
          "code": "3600608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-JTIP .025X33CM",
      "code_information": [
        {
          "code": "3600780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP726D",
      "code_information": [
        {
          "code": "3601389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SEDLINE RD",
      "code_information": [
        {
          "code": "3601706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMP SENSING 16FR 119216",
      "code_information": [
        {
          "code": "3601726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PREM CS006",
      "code_information": [
        {
          "code": "3601999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 0 VCPP31D",
      "code_information": [
        {
          "code": "3602463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-INSTRUMENT T50106",
      "code_information": [
        {
          "code": "3603056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63447",
      "code_information": [
        {
          "code": "3603065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63446",
      "code_information": [
        {
          "code": "3603066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63445",
      "code_information": [
        {
          "code": "3603067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE PMITCSG",
      "code_information": [
        {
          "code": "3603191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3603332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-BIOPSY ORT 27550ZAG/10",
      "code_information": [
        {
          "code": "3603541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG GOLD NR30001010",
      "code_information": [
        {
          "code": "3603912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NOMOLINE LH AIRWAY ADAPTER",
      "code_information": [
        {
          "code": "3603959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED W/ PEEP VALVE",
      "code_information": [
        {
          "code": "3603963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADULT W/ PEEP VAL",
      "code_information": [
        {
          "code": "3603964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION C2202",
      "code_information": [
        {
          "code": "3603996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP840D",
      "code_information": [
        {
          "code": "3604214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROVOX-DILATOR 8341",
      "code_information": [
        {
          "code": "3604745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PERFUSION PUMP 6320",
      "code_information": [
        {
          "code": "3604835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION 120MM",
      "code_information": [
        {
          "code": "3604953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-TRANSDUCER     K11-00096",
      "code_information": [
        {
          "code": "3820165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMPSENSING 16FR   117416",
      "code_information": [
        {
          "code": "3822997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL 4FR 20CM G02366",
      "code_information": [
        {
          "code": "3823450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY          000109",
      "code_information": [
        {
          "code": "4820900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION 16G",
      "code_information": [
        {
          "code": "4825435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 111.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 J305H",
      "code_information": [
        {
          "code": "3012910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL3-0 27\\\" FS-2",
      "code_information": [
        {
          "code": "3033304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-ETHICON         PCP-20",
      "code_information": [
        {
          "code": "3033960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUT-PDS 2-0 Z317H",
      "code_information": [
        {
          "code": "3059073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VIC 2-0           J317H",
      "code_information": [
        {
          "code": "3088957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J329H",
      "code_information": [
        {
          "code": "3088960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y215H",
      "code_information": [
        {
          "code": "3088973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y214H",
      "code_information": [
        {
          "code": "3088974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-RETENTION 450G",
      "code_information": [
        {
          "code": "3088984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 36\\\"        Z346H",
      "code_information": [
        {
          "code": "3088987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y398H",
      "code_information": [
        {
          "code": "3088989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J602H",
      "code_information": [
        {
          "code": "3088995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y346H",
      "code_information": [
        {
          "code": "3088999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL  0         J946G",
      "code_information": [
        {
          "code": "3089001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J603H",
      "code_information": [
        {
          "code": "3089003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J270H",
      "code_information": [
        {
          "code": "3089004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J341H",
      "code_information": [
        {
          "code": "3089009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J338H",
      "code_information": [
        {
          "code": "3089016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J311H",
      "code_information": [
        {
          "code": "3089021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRL 1        Y341H",
      "code_information": [
        {
          "code": "3089036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y340H",
      "code_information": [
        {
          "code": "3089037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8425H",
      "code_information": [
        {
          "code": "3089050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8424H",
      "code_information": [
        {
          "code": "3089052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8412H",
      "code_information": [
        {
          "code": "3089053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8433H",
      "code_information": [
        {
          "code": "3089062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8417H",
      "code_information": [
        {
          "code": "3089070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J633H",
      "code_information": [
        {
          "code": "3089091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0          802H",
      "code_information": [
        {
          "code": "3089130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1         S115H",
      "code_information": [
        {
          "code": "3089137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1          865H",
      "code_information": [
        {
          "code": "3089138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1          813H",
      "code_information": [
        {
          "code": "3089139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J370H",
      "code_information": [
        {
          "code": "3089144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 1       S105H",
      "code_information": [
        {
          "code": "3089149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            K835H",
      "code_information": [
        {
          "code": "3089164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            SA86G",
      "code_information": [
        {
          "code": "3089165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0      852H",
      "code_information": [
        {
          "code": "3089167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     H821H",
      "code_information": [
        {
          "code": "3089171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            A186H",
      "code_information": [
        {
          "code": "3089173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           623H",
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        {
          "code": "3089176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A184H",
      "code_information": [
        {
          "code": "3089178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3089183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A305H",
      "code_information": [
        {
          "code": "3089185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A185H",
      "code_information": [
        {
          "code": "3089186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K831H",
      "code_information": [
        {
          "code": "3089193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0           684H",
      "code_information": [
        {
          "code": "3089198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          A183H",
      "code_information": [
        {
          "code": "3089200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        636H",
      "code_information": [
        {
          "code": "3089205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X964H",
      "code_information": [
        {
          "code": "3089208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2        X519H",
      "code_information": [
        {
          "code": "3089213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X518H",
      "code_information": [
        {
          "code": "3089214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0       1674H",
      "code_information": [
        {
          "code": "3089236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1673H",
      "code_information": [
        {
          "code": "3089242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        627H",
      "code_information": [
        {
          "code": "3089245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z339H",
      "code_information": [
        {
          "code": "3089255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0   Z304H",
      "code_information": [
        {
          "code": "3089260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J442H",
      "code_information": [
        {
          "code": "3089274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 1689H",
      "code_information": [
        {
          "code": "3089276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            SA87G",
      "code_information": [
        {
          "code": "3089277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2          J880T",
      "code_information": [
        {
          "code": "3089278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2          460T",
      "code_information": [
        {
          "code": "3089298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J214H",
      "code_information": [
        {
          "code": "3089329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J662H",
      "code_information": [
        {
          "code": "3089339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J347H",
      "code_information": [
        {
          "code": "3089347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J335H",
      "code_information": [
        {
          "code": "3089359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X425H",
      "code_information": [
        {
          "code": "3089385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z333H",
      "code_information": [
        {
          "code": "3089395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 626H",
      "code_information": [
        {
          "code": "3089409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685H",
      "code_information": [
        {
          "code": "3500610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    684G",
      "code_information": [
        {
          "code": "3500770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          K872H",
      "code_information": [
        {
          "code": "3501015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 18FR 30CC      266718",
      "code_information": [
        {
          "code": "3507735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 0 PDP340H",
      "code_information": [
        {
          "code": "3526247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-3-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-3-0 PLUS",
      "code_information": [
        {
          "code": "3526254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 1 PDP341H",
      "code_information": [
        {
          "code": "3549733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 4-0 R633H",
      "code_information": [
        {
          "code": "3549987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        635G",
      "code_information": [
        {
          "code": "3555389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           622-H",
      "code_information": [
        {
          "code": "3557329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK O             624H",
      "code_information": [
        {
          "code": "3557386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            K834H",
      "code_information": [
        {
          "code": "3557388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           661-G",
      "code_information": [
        {
          "code": "3557535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           662-G",
      "code_information": [
        {
          "code": "3557568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           663-H",
      "code_information": [
        {
          "code": "3557592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 2.0        664G",
      "code_information": [
        {
          "code": "3557990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON            801H",
      "code_information": [
        {
          "code": "3558467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 3-0        1671-H",
      "code_information": [
        {
          "code": "3559001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         B-842-H",
      "code_information": [
        {
          "code": "3560064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH CHROMIC 3-0 G-122-H",
      "code_information": [
        {
          "code": "3560211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J219H",
      "code_information": [
        {
          "code": "3560487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J258H",
      "code_information": [
        {
          "code": "3560490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-259-H",
      "code_information": [
        {
          "code": "3560505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL          J-416-H",
      "code_information": [
        {
          "code": "3560745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J415H",
      "code_information": [
        {
          "code": "3560840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J417H",
      "code_information": [
        {
          "code": "3561410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        669H",
      "code_information": [
        {
          "code": "3561418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 3-0  J-944-H",
      "code_information": [
        {
          "code": "3561419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-832-H",
      "code_information": [
        {
          "code": "3561461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-833-H",
      "code_information": [
        {
          "code": "3561495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH MONOCRL 2-0   Y259H",
      "code_information": [
        {
          "code": "3562109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3.0    Y-338-H",
      "code_information": [
        {
          "code": "3562123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y416H",
      "code_information": [
        {
          "code": "3562126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0     H822H",
      "code_information": [
        {
          "code": "3562128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 FS-1    1629H",
      "code_information": [
        {
          "code": "3562140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8683G",
      "code_information": [
        {
          "code": "3562227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           683G",
      "code_information": [
        {
          "code": "3562240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K871H",
      "code_information": [
        {
          "code": "3562245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP316H",
      "code_information": [
        {
          "code": "3598241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP945G",
      "code_information": [
        {
          "code": "3598400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 J422H",
      "code_information": [
        {
          "code": "3598401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL SZ 1 36\\\" J519H",
      "code_information": [
        {
          "code": "3598406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS #1 VCP371H",
      "code_information": [
        {
          "code": "3598411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 G181H",
      "code_information": [
        {
          "code": "3598414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1670H",
      "code_information": [
        {
          "code": "3598421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 2-0 VCP195H",
      "code_information": [
        {
          "code": "3598422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ #1 VCP569H",
      "code_information": [
        {
          "code": "3598423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 4.0 VCP310H",
      "code_information": [
        {
          "code": "3598433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0 664H",
      "code_information": [
        {
          "code": "3598435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 J306H",
      "code_information": [
        {
          "code": "3598715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP311H",
      "code_information": [
        {
          "code": "3602123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 663G",
      "code_information": [
        {
          "code": "3602506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 2-0 MCP345H",
      "code_information": [
        {
          "code": "3602920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0   Y303H",
      "code_information": [
        {
          "code": "3603113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 VCP602H",
      "code_information": [
        {
          "code": "3603514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP305H",
      "code_information": [
        {
          "code": "3604136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP422H",
      "code_information": [
        {
          "code": "3604226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP218H",
      "code_information": [
        {
          "code": "3604353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 4-0 VCP434H",
      "code_information": [
        {
          "code": "3604548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP603H",
      "code_information": [
        {
          "code": "3604710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP946H",
      "code_information": [
        {
          "code": "3604711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BLK 3-0 18\\\"\\\" 642G",
      "code_information": [
        {
          "code": "3604940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        X424H",
      "code_information": [
        {
          "code": "3824629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J269H",
      "code_information": [
        {
          "code": "3824633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J232H",
      "code_information": [
        {
          "code": "3824634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J434H",
      "code_information": [
        {
          "code": "3824636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 30\\\"    X444H",
      "code_information": [
        {
          "code": "3824647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 27\\\"    J443H",
      "code_information": [
        {
          "code": "3824648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X411",
      "code_information": [
        {
          "code": "3824706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 8.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 7FR       06-107F",
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        {
          "code": "1415875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 MS-DC5020",
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        {
          "code": "3002250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          MS-DC28",
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        {
          "code": "3002372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DERMATOME 00-8800-000-10",
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        {
          "code": "3002650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-7.3 ARCH AORTIC MT022A",
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          "code": "3004031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHOULDER ALL AR-6500s",
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        {
          "code": "3004216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS HIFLO 24F 69324",
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          "code": "3004482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR        12002",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-5MM PROT BLUE 5027-1050",
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        {
          "code": "3004650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-34 DPSB DISP TOURNIQUET",
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        {
          "code": "3009958",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-42 DPSB DISP TOURNIQUET",
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        {
          "code": "3009959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPDB DISP TOURNIQUET",
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        {
          "code": "3009960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER TOP 44X44 ORS-100",
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        {
          "code": "3011925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-UTERINE MANIPULATOR",
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        {
          "code": "3019600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT         PI-104",
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        {
          "code": "3019880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MAGNUM BIOPSY    MN18xx",
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        {
          "code": "3027515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-PERI-OB DRAPE       2997",
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        {
          "code": "3034345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-CANNULA XI      470381",
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        {
          "code": "3039883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-SUTURE ASSISTANT  SW110",
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        {
          "code": "3039900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETAINER-VISCERA LARGE HS-3206",
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        {
          "code": "3040486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 BV-1 BLUE EPH9702H",
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        {
          "code": "3058802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 2xFR",
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        {
          "code": "3058922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL NEW",
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        {
          "code": "3059210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN",
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        {
          "code": "3059265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-VIA-GUARD SMP-2006-001",
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        {
          "code": "3060015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 16\\\" 7716-000-10",
      "code_information": [
        {
          "code": "3060133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THREADED 72200425",
      "code_information": [
        {
          "code": "3060484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-ELECTROLUBE         EL101",
      "code_information": [
        {
          "code": "3078867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING           031229-10",
      "code_information": [
        {
          "code": "3079239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNELER 16G     ACC10S",
      "code_information": [
        {
          "code": "3079464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SEPTAL NEIMAN  14-0441",
      "code_information": [
        {
          "code": "3080203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMDxx40x",
      "code_information": [
        {
          "code": "3082490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-EYE 10.0          7711G",
      "code_information": [
        {
          "code": "3082557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-IRRIG SUCT 250070530",
      "code_information": [
        {
          "code": "3083086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 45CM     3909",
      "code_information": [
        {
          "code": "3083636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-ONQ ALL         T1X's",
      "code_information": [
        {
          "code": "3086215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS ADAPTER",
      "code_information": [
        {
          "code": "3087517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 1010030",
      "code_information": [
        {
          "code": "3088591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 5        RS21",
      "code_information": [
        {
          "code": "3089261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-BLUE VLOCN0615",
      "code_information": [
        {
          "code": "3089401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXMP1B117",
      "code_information": [
        {
          "code": "3089421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 3.2MM        702462",
      "code_information": [
        {
          "code": "3091254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             1101",
      "code_information": [
        {
          "code": "3093210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS 420023",
      "code_information": [
        {
          "code": "3155010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS LONG",
      "code_information": [
        {
          "code": "3155020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION ADJ",
      "code_information": [
        {
          "code": "3311604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBIGRIP D 1437",
      "code_information": [
        {
          "code": "3503055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD           KVL03",
      "code_information": [
        {
          "code": "3504920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH X3-003-000",
      "code_information": [
        {
          "code": "3504921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 1L    622283",
      "code_information": [
        {
          "code": "3505720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 600ML 622278",
      "code_information": [
        {
          "code": "3505722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC FREEDOM 300ML",
      "code_information": [
        {
          "code": "3506124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CRITICORE URINARY  900216",
      "code_information": [
        {
          "code": "3506760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC ALL SZ",
      "code_information": [
        {
          "code": "3510098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYLOG 3000 DISPOSABLE",
      "code_information": [
        {
          "code": "3510130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COLLECTN BREAST MILK  67's",
      "code_information": [
        {
          "code": "3521700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE A ARTERIAL    400115A",
      "code_information": [
        {
          "code": "3521984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-KIWI OMNI SYSTEM",
      "code_information": [
        {
          "code": "3522453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22G X 20CM",
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        {
          "code": "3526117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PULSAVAC IRRIGATION",
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        {
          "code": "3526128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CYSTO           DYNJ49183",
      "code_information": [
        {
          "code": "3526166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-KENNEDY SINUS      400426",
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        {
          "code": "3526168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 30 SXPP1B410",
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        {
          "code": "3526382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 34 DPSB 60707010600",
      "code_information": [
        {
          "code": "3526496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMD2B401",
      "code_information": [
        {
          "code": "3526937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-HEEL SUSPENSION   M60-300",
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        {
          "code": "3528097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
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          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 42 DPSB 60707010700",
      "code_information": [
        {
          "code": "3529497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSORMAT-CHAIR-CHEC 65815-030",
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        {
          "code": "3541322",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 5FR TMI      1154",
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        {
          "code": "3541914",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ZONE NAVIGATOR AR790x",
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        {
          "code": "3547988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K OLIVE 2MM 703818",
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        {
          "code": "3549171",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAGITTAL 40X14X0.6",
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        {
          "code": "3549447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 5MM 0227-010-250",
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        {
          "code": "3549930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-INTRACK ULTRA 66MM",
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        {
          "code": "3550346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR A3",
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        {
          "code": "3550415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-C1/T1/MR1 EXPIRATORY 161",
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        {
          "code": "3550566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-COAXIAL BREATHING DISP",
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        {
          "code": "3550567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-WHEELCHAIR MEDIUM 565613",
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        {
          "code": "3550733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE",
      "code_information": [
        {
          "code": "3550798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.25X200MM A-5040.30/1",
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        {
          "code": "3550826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DELUXE KNEE/HIP 081603273",
      "code_information": [
        {
          "code": "3550839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTERPULSE HANDLE W TIP",
      "code_information": [
        {
          "code": "3550870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 12MM ONB12STF",
      "code_information": [
        {
          "code": "3559126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION A495LM",
      "code_information": [
        {
          "code": "3559184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AF541",
      "code_information": [
        {
          "code": "3559226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ4",
      "code_information": [
        {
          "code": "3559252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URI-CATH 3.5FR&5.0FR",
      "code_information": [
        {
          "code": "3566802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PROCEDURE PICC W/O PICC",
      "code_information": [
        {
          "code": "3570790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF 7.0MM",
      "code_information": [
        {
          "code": "3573939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 18GA    9001C0212",
      "code_information": [
        {
          "code": "3590035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 8.0MM",
      "code_information": [
        {
          "code": "3590138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-POLAR KNEE WRAP-ON",
      "code_information": [
        {
          "code": "3598080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 15' 251015J",
      "code_information": [
        {
          "code": "3598139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMP2B401",
      "code_information": [
        {
          "code": "3598157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER PAD F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH 5FR TMI1185",
      "code_information": [
        {
          "code": "3598221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSPAC TRIFURCATED 42800",
      "code_information": [
        {
          "code": "3598244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BONE MARROW 11GX4\\\" BAK451",
      "code_information": [
        {
          "code": "3598402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM BLADED CTB73",
      "code_information": [
        {
          "code": "3598438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4X70/16MM 607470",
      "code_information": [
        {
          "code": "3598460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 GORE-TEX 4N10B",
      "code_information": [
        {
          "code": "3598958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 18 FR",
      "code_information": [
        {
          "code": "3599116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 16 FR",
      "code_information": [
        {
          "code": "3599117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-NITINOL PILOT 5901-6072",
      "code_information": [
        {
          "code": "3599187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/25CM MN1825",
      "code_information": [
        {
          "code": "3599317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSIONS-CABLE DISP 4051L",
      "code_information": [
        {
          "code": "3599647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.1CM",
      "code_information": [
        {
          "code": "3600164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL EVF1XMLSLA",
      "code_information": [
        {
          "code": "3600224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.6X150MM P99-292-1615",
      "code_information": [
        {
          "code": "3600326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-CAPTURA DISP G53006",
      "code_information": [
        {
          "code": "3600504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-192-2330",
      "code_information": [
        {
          "code": "3600521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TENNIS RACQUET 5FR/90CM",
      "code_information": [
        {
          "code": "3600554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ 3",
      "code_information": [
        {
          "code": "3600778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-2.0X200MM P99-192-2020",
      "code_information": [
        {
          "code": "3601106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,GASTRO MIC",
      "code_information": [
        {
          "code": "3601451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MIAR 14G 7FR 11014L",
      "code_information": [
        {
          "code": "3601478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-OSIA OSI200 P1291019",
      "code_information": [
        {
          "code": "3601610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300 NTHRD 702463",
      "code_information": [
        {
          "code": "3601870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-193-2323",
      "code_information": [
        {
          "code": "3602140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.1MM AR-8655K-11",
      "code_information": [
        {
          "code": "3602154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SHEATH W/CATH SA-09847",
      "code_information": [
        {
          "code": "3602436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PT PUMP 8\\\"\\\" AR-6421",
      "code_information": [
        {
          "code": "3602461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-RING 16\\\" DUR8016W",
      "code_information": [
        {
          "code": "3602526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.2X150 TH P99-193-1215",
      "code_information": [
        {
          "code": "3602570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP TRB29-LRG",
      "code_information": [
        {
          "code": "3602758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.0X200MM P99-193-2020",
      "code_information": [
        {
          "code": "3602993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X100MM P99-192-1410",
      "code_information": [
        {
          "code": "3603370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-BIVENTRICULAR BS-101-97",
      "code_information": [
        {
          "code": "3603546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 3-0 PS-2",
      "code_information": [
        {
          "code": "3603921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.4X15 MSG14150",
      "code_information": [
        {
          "code": "3604046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.6X15 MSG16150",
      "code_information": [
        {
          "code": "3604056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X150MM P99-292-0915",
      "code_information": [
        {
          "code": "3604177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X150 SM P99-192-2315",
      "code_information": [
        {
          "code": "3604181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-292-1115",
      "code_information": [
        {
          "code": "3604182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1615",
      "code_information": [
        {
          "code": "3604183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1415",
      "code_information": [
        {
          "code": "3604184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-U-FRAME STRD MT-APU-2.4",
      "code_information": [
        {
          "code": "3604229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADS-LACURA VISCO FOOT",
      "code_information": [
        {
          "code": "3604310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-HEX 10MM 76-10185",
      "code_information": [
        {
          "code": "3604312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-GUARDIAN HEMOSTAT 8215",
      "code_information": [
        {
          "code": "3604336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-WASTE 04369",
      "code_information": [
        {
          "code": "3604367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K .9X150MM P99-192-0915",
      "code_information": [
        {
          "code": "3604377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG 900-152",
      "code_information": [
        {
          "code": "3604585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD-EX 900-154",
      "code_information": [
        {
          "code": "3604586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD 900-151",
      "code_information": [
        {
          "code": "3604587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG-SHL 900-155",
      "code_information": [
        {
          "code": "3604588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FINGER SMALL 9906",
      "code_information": [
        {
          "code": "3604630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CARDIOPLEGIA CA-20010",
      "code_information": [
        {
          "code": "3604878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-192-1115",
      "code_information": [
        {
          "code": "3605071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING ADAP-2000",
      "code_information": [
        {
          "code": "3820230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP 29CM   3529",
      "code_information": [
        {
          "code": "3823445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR REPLACEMENT",
      "code_information": [
        {
          "code": "3824192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 18FR REPLACEMENT",
      "code_information": [
        {
          "code": "3824193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 20FR REPLACEMENT",
      "code_information": [
        {
          "code": "3824194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X44MM 607344",
      "code_information": [
        {
          "code": "3900032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X14MM 661714",
      "code_information": [
        {
          "code": "3900033",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X16MM 661716",
      "code_information": [
        {
          "code": "3900034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X18MM 661718",
      "code_information": [
        {
          "code": "3900035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X20MM 661720",
      "code_information": [
        {
          "code": "3900036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X36MM 661736",
      "code_information": [
        {
          "code": "3900037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X38MM 661738",
      "code_information": [
        {
          "code": "3900038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X70MM 661770",
      "code_information": [
        {
          "code": "3900039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X75MM 661775",
      "code_information": [
        {
          "code": "3900040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X80MM 661780",
      "code_information": [
        {
          "code": "3900041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X90MM 661790",
      "code_information": [
        {
          "code": "3900042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X95MM 661795",
      "code_information": [
        {
          "code": "3900043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X120MM 5079-5-120",
      "code_information": [
        {
          "code": "3900044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X150MM 5079-5-150",
      "code_information": [
        {
          "code": "3900045",
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        {
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-NLOCK FT 2.7X8MM 657108",
      "code_information": [
        {
          "code": "3900140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-NLOCK FT 3.5X65MM 657465",
      "code_information": [
        {
          "code": "3900141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-NLOCK FT 3.5X70MM 657470",
      "code_information": [
        {
          "code": "3900142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 4.0X85MM 661085",
      "code_information": [
        {
          "code": "3900213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW",
      "code_information": [
        {
          "code": "4823650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR   NM-400U-0525",
      "code_information": [
        {
          "code": "4825515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD 3.2MM MT-APU",
      "code_information": [
        {
          "code": "5750663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HPN",
              "standard_charge_dollar": 232.144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 7FR       06-107F",
      "code_information": [
        {
          "code": "1415875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 MS-DC5020",
      "code_information": [
        {
          "code": "3002250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          MS-DC28",
      "code_information": [
        {
          "code": "3002372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DERMATOME 00-8800-000-10",
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        {
          "code": "3002650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-7.3 ARCH AORTIC MT022A",
      "code_information": [
        {
          "code": "3004031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHOULDER ALL AR-6500s",
      "code_information": [
        {
          "code": "3004216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS HIFLO 24F 69324",
      "code_information": [
        {
          "code": "3004482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR        12002",
      "code_information": [
        {
          "code": "3004521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-5MM PROT BLUE 5027-1050",
      "code_information": [
        {
          "code": "3004650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-42 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER TOP 44X44 ORS-100",
      "code_information": [
        {
          "code": "3011925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT         PI-104",
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        {
          "code": "3019880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MAGNUM BIOPSY    MN18xx",
      "code_information": [
        {
          "code": "3027515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-PERI-OB DRAPE       2997",
      "code_information": [
        {
          "code": "3034345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-CANNULA XI      470381",
      "code_information": [
        {
          "code": "3039883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-SUTURE ASSISTANT  SW110",
      "code_information": [
        {
          "code": "3039900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETAINER-VISCERA LARGE HS-3206",
      "code_information": [
        {
          "code": "3040486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 BV-1 BLUE EPH9702H",
      "code_information": [
        {
          "code": "3058802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 2xFR",
      "code_information": [
        {
          "code": "3058922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL NEW",
      "code_information": [
        {
          "code": "3059210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN",
      "code_information": [
        {
          "code": "3059265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-VIA-GUARD SMP-2006-001",
      "code_information": [
        {
          "code": "3060015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 16\\\" 7716-000-10",
      "code_information": [
        {
          "code": "3060133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THREADED 72200425",
      "code_information": [
        {
          "code": "3060484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-ELECTROLUBE         EL101",
      "code_information": [
        {
          "code": "3078867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING           031229-10",
      "code_information": [
        {
          "code": "3079239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNELER 16G     ACC10S",
      "code_information": [
        {
          "code": "3079464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SEPTAL NEIMAN  14-0441",
      "code_information": [
        {
          "code": "3080203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMDxx40x",
      "code_information": [
        {
          "code": "3082490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-EYE 10.0          7711G",
      "code_information": [
        {
          "code": "3082557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-IRRIG SUCT 250070530",
      "code_information": [
        {
          "code": "3083086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 45CM     3909",
      "code_information": [
        {
          "code": "3083636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-ONQ ALL         T1X's",
      "code_information": [
        {
          "code": "3086215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS ADAPTER",
      "code_information": [
        {
          "code": "3087517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 1010030",
      "code_information": [
        {
          "code": "3088591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 5        RS21",
      "code_information": [
        {
          "code": "3089261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-BLUE VLOCN0615",
      "code_information": [
        {
          "code": "3089401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXMP1B117",
      "code_information": [
        {
          "code": "3089421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 3.2MM        702462",
      "code_information": [
        {
          "code": "3091254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             1101",
      "code_information": [
        {
          "code": "3093210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS 420023",
      "code_information": [
        {
          "code": "3155010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS LONG",
      "code_information": [
        {
          "code": "3155020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION ADJ",
      "code_information": [
        {
          "code": "3311604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBIGRIP D 1437",
      "code_information": [
        {
          "code": "3503055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD           KVL03",
      "code_information": [
        {
          "code": "3504920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH X3-003-000",
      "code_information": [
        {
          "code": "3504921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 1L    622283",
      "code_information": [
        {
          "code": "3505720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 600ML 622278",
      "code_information": [
        {
          "code": "3505722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC FREEDOM 300ML",
      "code_information": [
        {
          "code": "3506124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CRITICORE URINARY  900216",
      "code_information": [
        {
          "code": "3506760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC ALL SZ",
      "code_information": [
        {
          "code": "3510098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYLOG 3000 DISPOSABLE",
      "code_information": [
        {
          "code": "3510130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COLLECTN BREAST MILK  67's",
      "code_information": [
        {
          "code": "3521700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE A ARTERIAL    400115A",
      "code_information": [
        {
          "code": "3521984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-KIWI OMNI SYSTEM",
      "code_information": [
        {
          "code": "3522453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22G X 20CM",
      "code_information": [
        {
          "code": "3526117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PULSAVAC IRRIGATION",
      "code_information": [
        {
          "code": "3526128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-KENNEDY SINUS      400426",
      "code_information": [
        {
          "code": "3526168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 30 SXPP1B410",
      "code_information": [
        {
          "code": "3526382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 34 DPSB 60707010600",
      "code_information": [
        {
          "code": "3526496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMD2B401",
      "code_information": [
        {
          "code": "3526937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-HEEL SUSPENSION   M60-300",
      "code_information": [
        {
          "code": "3528097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 42 DPSB 60707010700",
      "code_information": [
        {
          "code": "3529497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSORMAT-CHAIR-CHEC 65815-030",
      "code_information": [
        {
          "code": "3541322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 5FR TMI      1154",
      "code_information": [
        {
          "code": "3541914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ZONE NAVIGATOR AR790x",
      "code_information": [
        {
          "code": "3547988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K OLIVE 2MM 703818",
      "code_information": [
        {
          "code": "3549171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAGITTAL 40X14X0.6",
      "code_information": [
        {
          "code": "3549447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 5MM 0227-010-250",
      "code_information": [
        {
          "code": "3549930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-INTRACK ULTRA 66MM",
      "code_information": [
        {
          "code": "3550346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR A3",
      "code_information": [
        {
          "code": "3550415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-C1/T1/MR1 EXPIRATORY 161",
      "code_information": [
        {
          "code": "3550566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-COAXIAL BREATHING DISP",
      "code_information": [
        {
          "code": "3550567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-WHEELCHAIR MEDIUM 565613",
      "code_information": [
        {
          "code": "3550733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE",
      "code_information": [
        {
          "code": "3550798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.25X200MM A-5040.30/1",
      "code_information": [
        {
          "code": "3550826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DELUXE KNEE/HIP 081603273",
      "code_information": [
        {
          "code": "3550839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTERPULSE HANDLE W TIP",
      "code_information": [
        {
          "code": "3550870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 12MM ONB12STF",
      "code_information": [
        {
          "code": "3559126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION A495LM",
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        {
          "code": "3559184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AF541",
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        {
          "code": "3559226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ4",
      "code_information": [
        {
          "code": "3559252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URI-CATH 3.5FR&5.0FR",
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        {
          "code": "3566802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PROCEDURE PICC W/O PICC",
      "code_information": [
        {
          "code": "3570790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
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        {
          "code": "3573907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF 7.0MM",
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        {
          "code": "3573939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 18GA    9001C0212",
      "code_information": [
        {
          "code": "3590035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 8.0MM",
      "code_information": [
        {
          "code": "3590138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-POLAR KNEE WRAP-ON",
      "code_information": [
        {
          "code": "3598080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 15' 251015J",
      "code_information": [
        {
          "code": "3598139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMP2B401",
      "code_information": [
        {
          "code": "3598157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER PAD F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH 5FR TMI1185",
      "code_information": [
        {
          "code": "3598221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSPAC TRIFURCATED 42800",
      "code_information": [
        {
          "code": "3598244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BONE MARROW 11GX4\\\" BAK451",
      "code_information": [
        {
          "code": "3598402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM BLADED CTB73",
      "code_information": [
        {
          "code": "3598438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4X70/16MM 607470",
      "code_information": [
        {
          "code": "3598460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 GORE-TEX 4N10B",
      "code_information": [
        {
          "code": "3598958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 18 FR",
      "code_information": [
        {
          "code": "3599116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 16 FR",
      "code_information": [
        {
          "code": "3599117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-NITINOL PILOT 5901-6072",
      "code_information": [
        {
          "code": "3599187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/25CM MN1825",
      "code_information": [
        {
          "code": "3599317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSIONS-CABLE DISP 4051L",
      "code_information": [
        {
          "code": "3599647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.1CM",
      "code_information": [
        {
          "code": "3600164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL EVF1XMLSLA",
      "code_information": [
        {
          "code": "3600224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.6X150MM P99-292-1615",
      "code_information": [
        {
          "code": "3600326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-CAPTURA DISP G53006",
      "code_information": [
        {
          "code": "3600504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-192-2330",
      "code_information": [
        {
          "code": "3600521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TENNIS RACQUET 5FR/90CM",
      "code_information": [
        {
          "code": "3600554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ 3",
      "code_information": [
        {
          "code": "3600778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-2.0X200MM P99-192-2020",
      "code_information": [
        {
          "code": "3601106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,GASTRO MIC",
      "code_information": [
        {
          "code": "3601451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MIAR 14G 7FR 11014L",
      "code_information": [
        {
          "code": "3601478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-OSIA OSI200 P1291019",
      "code_information": [
        {
          "code": "3601610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300 NTHRD 702463",
      "code_information": [
        {
          "code": "3601870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-193-2323",
      "code_information": [
        {
          "code": "3602140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.1MM AR-8655K-11",
      "code_information": [
        {
          "code": "3602154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SHEATH W/CATH SA-09847",
      "code_information": [
        {
          "code": "3602436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PT PUMP 8\\\"\\\" AR-6421",
      "code_information": [
        {
          "code": "3602461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-RING 16\\\" DUR8016W",
      "code_information": [
        {
          "code": "3602526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.2X150 TH P99-193-1215",
      "code_information": [
        {
          "code": "3602570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP TRB29-LRG",
      "code_information": [
        {
          "code": "3602758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.0X200MM P99-193-2020",
      "code_information": [
        {
          "code": "3602993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X100MM P99-192-1410",
      "code_information": [
        {
          "code": "3603370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-BIVENTRICULAR BS-101-97",
      "code_information": [
        {
          "code": "3603546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 3-0 PS-2",
      "code_information": [
        {
          "code": "3603921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.4X15 MSG14150",
      "code_information": [
        {
          "code": "3604046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.6X15 MSG16150",
      "code_information": [
        {
          "code": "3604056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X150MM P99-292-0915",
      "code_information": [
        {
          "code": "3604177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X150 SM P99-192-2315",
      "code_information": [
        {
          "code": "3604181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-292-1115",
      "code_information": [
        {
          "code": "3604182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1615",
      "code_information": [
        {
          "code": "3604183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1415",
      "code_information": [
        {
          "code": "3604184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-U-FRAME STRD MT-APU-2.4",
      "code_information": [
        {
          "code": "3604229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADS-LACURA VISCO FOOT",
      "code_information": [
        {
          "code": "3604310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-HEX 10MM 76-10185",
      "code_information": [
        {
          "code": "3604312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-GUARDIAN HEMOSTAT 8215",
      "code_information": [
        {
          "code": "3604336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-WASTE 04369",
      "code_information": [
        {
          "code": "3604367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K .9X150MM P99-192-0915",
      "code_information": [
        {
          "code": "3604377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG 900-152",
      "code_information": [
        {
          "code": "3604585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD-EX 900-154",
      "code_information": [
        {
          "code": "3604586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD 900-151",
      "code_information": [
        {
          "code": "3604587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG-SHL 900-155",
      "code_information": [
        {
          "code": "3604588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FINGER SMALL 9906",
      "code_information": [
        {
          "code": "3604630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CARDIOPLEGIA CA-20010",
      "code_information": [
        {
          "code": "3604878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-192-1115",
      "code_information": [
        {
          "code": "3605071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING ADAP-2000",
      "code_information": [
        {
          "code": "3820230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP 29CM   3529",
      "code_information": [
        {
          "code": "3823445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR REPLACEMENT",
      "code_information": [
        {
          "code": "3824192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 18FR REPLACEMENT",
      "code_information": [
        {
          "code": "3824193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 20FR REPLACEMENT",
      "code_information": [
        {
          "code": "3824194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X44MM 607344",
      "code_information": [
        {
          "code": "3900032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X14MM 661714",
      "code_information": [
        {
          "code": "3900033",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X16MM 661716",
      "code_information": [
        {
          "code": "3900034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X18MM 661718",
      "code_information": [
        {
          "code": "3900035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X20MM 661720",
      "code_information": [
        {
          "code": "3900036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X36MM 661736",
      "code_information": [
        {
          "code": "3900037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X38MM 661738",
      "code_information": [
        {
          "code": "3900038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X70MM 661770",
      "code_information": [
        {
          "code": "3900039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CORTEX 4.5X75MM 661775",
      "code_information": [
        {
          "code": "3900040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
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            }
          ]
        }
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    },
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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            }
          ]
        }
      ],
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    },
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        },
        {
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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              "payer_name": "Anthem",
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        {
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        {
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              "payer_name": "Anthem",
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        {
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              "payer_name": "Anthem",
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            }
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        }
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        {
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            }
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            }
          ]
        }
      ],
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        }
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            }
          ]
        }
      ],
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        {
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            }
          ]
        }
      ],
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        {
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            }
          ]
        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
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        {
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          ]
        }
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          ]
        }
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          ]
        }
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        {
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        }
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        }
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        {
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            }
          ]
        }
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            }
          ]
        }
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
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      "description": "SCREW-BONE FT  2.7X40MM 656440",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT  2.7X45MM 656445",
      "code_information": [
        {
          "code": "3900115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT  2.7X50MM 656450",
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        {
          "code": "3900116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT 2.7X8MM 656408",
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        {
          "code": "3900117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-NLOCK FT 2.7X70MM 657170",
      "code_information": [
        {
          "code": "3900139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-NLOCK FT 2.7X8MM 657108",
      "code_information": [
        {
          "code": "3900140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-NLOCK FT 3.5X65MM 657465",
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        {
          "code": "3900141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-NLOCK FT 3.5X70MM 657470",
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        {
          "code": "3900142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 4.0X85MM 661085",
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        {
          "code": "3900213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW",
      "code_information": [
        {
          "code": "4823650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR   NM-400U-0525",
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        {
          "code": "4825515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD 3.2MM MT-APU",
      "code_information": [
        {
          "code": "5750663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 J305H",
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        {
          "code": "3012910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL3-0 27\\\" FS-2",
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        {
          "code": "3033304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-ETHICON         PCP-20",
      "code_information": [
        {
          "code": "3033960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUT-PDS 2-0 Z317H",
      "code_information": [
        {
          "code": "3059073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VIC 2-0           J317H",
      "code_information": [
        {
          "code": "3088957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J329H",
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        {
          "code": "3088960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y215H",
      "code_information": [
        {
          "code": "3088973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y214H",
      "code_information": [
        {
          "code": "3088974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-RETENTION 450G",
      "code_information": [
        {
          "code": "3088984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 36\\\"        Z346H",
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        {
          "code": "3088987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y398H",
      "code_information": [
        {
          "code": "3088989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J602H",
      "code_information": [
        {
          "code": "3088995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y346H",
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        {
          "code": "3088999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL  0         J946G",
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        {
          "code": "3089001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J603H",
      "code_information": [
        {
          "code": "3089003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J270H",
      "code_information": [
        {
          "code": "3089004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J341H",
      "code_information": [
        {
          "code": "3089009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J338H",
      "code_information": [
        {
          "code": "3089016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J311H",
      "code_information": [
        {
          "code": "3089021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRL 1        Y341H",
      "code_information": [
        {
          "code": "3089036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y340H",
      "code_information": [
        {
          "code": "3089037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8425H",
      "code_information": [
        {
          "code": "3089050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8424H",
      "code_information": [
        {
          "code": "3089052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8412H",
      "code_information": [
        {
          "code": "3089053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8433H",
      "code_information": [
        {
          "code": "3089062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8417H",
      "code_information": [
        {
          "code": "3089070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J633H",
      "code_information": [
        {
          "code": "3089091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0          802H",
      "code_information": [
        {
          "code": "3089130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1         S115H",
      "code_information": [
        {
          "code": "3089137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1          865H",
      "code_information": [
        {
          "code": "3089138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1          813H",
      "code_information": [
        {
          "code": "3089139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J370H",
      "code_information": [
        {
          "code": "3089144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 1       S105H",
      "code_information": [
        {
          "code": "3089149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            K835H",
      "code_information": [
        {
          "code": "3089164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            SA86G",
      "code_information": [
        {
          "code": "3089165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0      852H",
      "code_information": [
        {
          "code": "3089167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     H821H",
      "code_information": [
        {
          "code": "3089171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            A186H",
      "code_information": [
        {
          "code": "3089173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           623H",
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        {
          "code": "3089176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A184H",
      "code_information": [
        {
          "code": "3089178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3089183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A305H",
      "code_information": [
        {
          "code": "3089185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A185H",
      "code_information": [
        {
          "code": "3089186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K831H",
      "code_information": [
        {
          "code": "3089193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0           684H",
      "code_information": [
        {
          "code": "3089198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          A183H",
      "code_information": [
        {
          "code": "3089200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        636H",
      "code_information": [
        {
          "code": "3089205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X964H",
      "code_information": [
        {
          "code": "3089208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2        X519H",
      "code_information": [
        {
          "code": "3089213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X518H",
      "code_information": [
        {
          "code": "3089214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0       1674H",
      "code_information": [
        {
          "code": "3089236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1673H",
      "code_information": [
        {
          "code": "3089242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        627H",
      "code_information": [
        {
          "code": "3089245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z339H",
      "code_information": [
        {
          "code": "3089255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0   Z304H",
      "code_information": [
        {
          "code": "3089260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J442H",
      "code_information": [
        {
          "code": "3089274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 1689H",
      "code_information": [
        {
          "code": "3089276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            SA87G",
      "code_information": [
        {
          "code": "3089277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2          J880T",
      "code_information": [
        {
          "code": "3089278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2          460T",
      "code_information": [
        {
          "code": "3089298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J214H",
      "code_information": [
        {
          "code": "3089329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J662H",
      "code_information": [
        {
          "code": "3089339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J347H",
      "code_information": [
        {
          "code": "3089347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J335H",
      "code_information": [
        {
          "code": "3089359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X425H",
      "code_information": [
        {
          "code": "3089385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z333H",
      "code_information": [
        {
          "code": "3089395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 626H",
      "code_information": [
        {
          "code": "3089409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685H",
      "code_information": [
        {
          "code": "3500610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    684G",
      "code_information": [
        {
          "code": "3500770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          K872H",
      "code_information": [
        {
          "code": "3501015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 18FR 30CC      266718",
      "code_information": [
        {
          "code": "3507735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 0 PDP340H",
      "code_information": [
        {
          "code": "3526247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-3-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-3-0 PLUS",
      "code_information": [
        {
          "code": "3526254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 1 PDP341H",
      "code_information": [
        {
          "code": "3549733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 4-0 R633H",
      "code_information": [
        {
          "code": "3549987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        635G",
      "code_information": [
        {
          "code": "3555389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           622-H",
      "code_information": [
        {
          "code": "3557329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK O             624H",
      "code_information": [
        {
          "code": "3557386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            K834H",
      "code_information": [
        {
          "code": "3557388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           661-G",
      "code_information": [
        {
          "code": "3557535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           662-G",
      "code_information": [
        {
          "code": "3557568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           663-H",
      "code_information": [
        {
          "code": "3557592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 2.0        664G",
      "code_information": [
        {
          "code": "3557990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON            801H",
      "code_information": [
        {
          "code": "3558467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 3-0        1671-H",
      "code_information": [
        {
          "code": "3559001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         B-842-H",
      "code_information": [
        {
          "code": "3560064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH CHROMIC 3-0 G-122-H",
      "code_information": [
        {
          "code": "3560211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J219H",
      "code_information": [
        {
          "code": "3560487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J258H",
      "code_information": [
        {
          "code": "3560490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-259-H",
      "code_information": [
        {
          "code": "3560505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL          J-416-H",
      "code_information": [
        {
          "code": "3560745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J415H",
      "code_information": [
        {
          "code": "3560840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J417H",
      "code_information": [
        {
          "code": "3561410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        669H",
      "code_information": [
        {
          "code": "3561418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 3-0  J-944-H",
      "code_information": [
        {
          "code": "3561419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-832-H",
      "code_information": [
        {
          "code": "3561461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-833-H",
      "code_information": [
        {
          "code": "3561495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH MONOCRL 2-0   Y259H",
      "code_information": [
        {
          "code": "3562109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3.0    Y-338-H",
      "code_information": [
        {
          "code": "3562123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y416H",
      "code_information": [
        {
          "code": "3562126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0     H822H",
      "code_information": [
        {
          "code": "3562128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 FS-1    1629H",
      "code_information": [
        {
          "code": "3562140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8683G",
      "code_information": [
        {
          "code": "3562227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           683G",
      "code_information": [
        {
          "code": "3562240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K871H",
      "code_information": [
        {
          "code": "3562245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP316H",
      "code_information": [
        {
          "code": "3598241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP945G",
      "code_information": [
        {
          "code": "3598400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 J422H",
      "code_information": [
        {
          "code": "3598401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL SZ 1 36\\\" J519H",
      "code_information": [
        {
          "code": "3598406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS #1 VCP371H",
      "code_information": [
        {
          "code": "3598411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 G181H",
      "code_information": [
        {
          "code": "3598414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1670H",
      "code_information": [
        {
          "code": "3598421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 2-0 VCP195H",
      "code_information": [
        {
          "code": "3598422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ #1 VCP569H",
      "code_information": [
        {
          "code": "3598423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 4.0 VCP310H",
      "code_information": [
        {
          "code": "3598433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0 664H",
      "code_information": [
        {
          "code": "3598435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 J306H",
      "code_information": [
        {
          "code": "3598715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP311H",
      "code_information": [
        {
          "code": "3602123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 663G",
      "code_information": [
        {
          "code": "3602506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 2-0 MCP345H",
      "code_information": [
        {
          "code": "3602920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0   Y303H",
      "code_information": [
        {
          "code": "3603113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 VCP602H",
      "code_information": [
        {
          "code": "3603514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP305H",
      "code_information": [
        {
          "code": "3604136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP422H",
      "code_information": [
        {
          "code": "3604226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP218H",
      "code_information": [
        {
          "code": "3604353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 4-0 VCP434H",
      "code_information": [
        {
          "code": "3604548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP603H",
      "code_information": [
        {
          "code": "3604710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP946H",
      "code_information": [
        {
          "code": "3604711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BLK 3-0 18\\\"\\\" 642G",
      "code_information": [
        {
          "code": "3604940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        X424H",
      "code_information": [
        {
          "code": "3824629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J269H",
      "code_information": [
        {
          "code": "3824633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J232H",
      "code_information": [
        {
          "code": "3824634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J434H",
      "code_information": [
        {
          "code": "3824636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 30\\\"    X444H",
      "code_information": [
        {
          "code": "3824647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 27\\\"    J443H",
      "code_information": [
        {
          "code": "3824648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X411",
      "code_information": [
        {
          "code": "3824706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-TOUHY BORST W/SIDE ARM",
      "code_information": [
        {
          "code": "1410050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-FEMORAL ANGIO  DYNJP4119",
      "code_information": [
        {
          "code": "1410800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18GX10CM   G01559",
      "code_information": [
        {
          "code": "1410916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-15      G03955",
      "code_information": [
        {
          "code": "1410919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CLOSED NEEDLE  LNGC-2022",
      "code_information": [
        {
          "code": "1495266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 9G EVIVA",
      "code_information": [
        {
          "code": "1495267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SWIVEL PORTEX 625191",
      "code_information": [
        {
          "code": "3002219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT ANT- 1012S",
      "code_information": [
        {
          "code": "3004017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-RANEY SCALP ADULT 20-1037",
      "code_information": [
        {
          "code": "3008833",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE       PMI-TC-SG",
      "code_information": [
        {
          "code": "3010072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE FUZZY       FZ624",
      "code_information": [
        {
          "code": "3020107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LID-COLLECTION DISP    BKC-506",
      "code_information": [
        {
          "code": "3021629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SURGISAFE ABSORB WHITE",
      "code_information": [
        {
          "code": "3029216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-UNIVRSL I AURO DYNJP1050A",
      "code_information": [
        {
          "code": "3029269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 10CM    70890856",
      "code_information": [
        {
          "code": "3029291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-STENT 6FR M0061802011",
      "code_information": [
        {
          "code": "3038668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR MANIFOLD",
      "code_information": [
        {
          "code": "3050023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 CX21D",
      "code_information": [
        {
          "code": "3058821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TRU               2C4041",
      "code_information": [
        {
          "code": "3079241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY METER ALL P4PxxULD",
      "code_information": [
        {
          "code": "3084872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COAG SUCTION      050-005",
      "code_information": [
        {
          "code": "3085551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ELECTROSURGICAL 8\\\"050-010",
      "code_information": [
        {
          "code": "3085595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX OUTFLOW AQL-111",
      "code_information": [
        {
          "code": "3086104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-3/8\\\"X3/32\\\"X8'     3508S",
      "code_information": [
        {
          "code": "3086137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8702H",
      "code_information": [
        {
          "code": "3089122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          JJ31G",
      "code_information": [
        {
          "code": "3089143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C016D",
      "code_information": [
        {
          "code": "3089188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 6-0          1732G",
      "code_information": [
        {
          "code": "3089203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX41",
      "code_information": [
        {
          "code": "3089216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J840D",
      "code_information": [
        {
          "code": "3089388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 CX22D",
      "code_information": [
        {
          "code": "3089700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-AERO          58-79510",
      "code_information": [
        {
          "code": "3284351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHARMBER-HEATER MR290",
      "code_information": [
        {
          "code": "3290069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ENDO TUBE ANCHORFAST",
      "code_information": [
        {
          "code": "3290137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ9 8.5CM",
      "code_information": [
        {
          "code": "3311077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PULLEY-OVERDOOR LUM101P",
      "code_information": [
        {
          "code": "3311351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-DERMABOND MINI",
      "code_information": [
        {
          "code": "3500037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SPIKE PRIMING   101593",
      "code_information": [
        {
          "code": "3500089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-HYPERINFLATION   1/2 LITER",
      "code_information": [
        {
          "code": "3501291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CAPNOLINE 11996-000163",
      "code_information": [
        {
          "code": "3501717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT TALL LF/ALUM 7704",
      "code_information": [
        {
          "code": "3511782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHANNEL ALL JP22xx",
      "code_information": [
        {
          "code": "3512580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 F/PEDS PEDICAP6",
      "code_information": [
        {
          "code": "3512772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LTA MADGIC       MAD600",
      "code_information": [
        {
          "code": "3512793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL LRG     L-35MM",
      "code_information": [
        {
          "code": "3513122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3514273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEEDER-SPECIALNEEDS 80ML 6000S",
      "code_information": [
        {
          "code": "3515912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLD MIC 40M SQ40SK",
      "code_information": [
        {
          "code": "3516131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE ALL SZS     N7s",
      "code_information": [
        {
          "code": "3519400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-KNEE 22\\\"   1220917",
      "code_information": [
        {
          "code": "3519967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7089-0844",
      "code_information": [
        {
          "code": "3526221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 J864D",
      "code_information": [
        {
          "code": "3526246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 8X18",
      "code_information": [
        {
          "code": "3526255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP839D",
      "code_information": [
        {
          "code": "3526344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP838",
      "code_information": [
        {
          "code": "3526348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTOR-ADULT INTUBATED AIRWAY",
      "code_information": [
        {
          "code": "3526527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GROMMET-BEVELED VENT 70241350",
      "code_information": [
        {
          "code": "3527288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS INF-L",
      "code_information": [
        {
          "code": "3541326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS NEO-L",
      "code_information": [
        {
          "code": "3541327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DELIVER MORGAN LENS MT202",
      "code_information": [
        {
          "code": "3541942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD/IV FLUID WARMER L-70",
      "code_information": [
        {
          "code": "3542396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM PREMIE N4901",
      "code_information": [
        {
          "code": "3549181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 24 JP-2234",
      "code_information": [
        {
          "code": "3549296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOCKS-TISSUE FLT-010",
      "code_information": [
        {
          "code": "3549777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIRROR-INSPECTION DIABETIC 081",
      "code_information": [
        {
          "code": "3550157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM INFANT N4902",
      "code_information": [
        {
          "code": "3550255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVES-SKIL-CARE GERI SM 5669",
      "code_information": [
        {
          "code": "3550329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH MALE EXTERNAL MECSB01",
      "code_information": [
        {
          "code": "3550510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF LG MDS601LD",
      "code_information": [
        {
          "code": "3550554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE,MERSILINE 4-0 S-2 1779G",
      "code_information": [
        {
          "code": "3550847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT ANES 2L 72\\\"",
      "code_information": [
        {
          "code": "3559130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 S-14",
      "code_information": [
        {
          "code": "3559177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP774D",
      "code_information": [
        {
          "code": "3559182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-UNDER NOSE",
      "code_information": [
        {
          "code": "3559270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2350H",
      "code_information": [
        {
          "code": "3559280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 15 JP-2228",
      "code_information": [
        {
          "code": "3559392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 19 JP-2230",
      "code_information": [
        {
          "code": "3559393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-HUMIDIFER MR290V",
      "code_information": [
        {
          "code": "3559432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET NEO",
      "code_information": [
        {
          "code": "3559609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         C-017-D",
      "code_information": [
        {
          "code": "3560077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4258705",
      "code_information": [
        {
          "code": "3568756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-COBAN 2LAYER         2094",
      "code_information": [
        {
          "code": "3575850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND UNIVERSAL RT/LT LG",
      "code_information": [
        {
          "code": "3580012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIV 9006-00",
      "code_information": [
        {
          "code": "3580022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3598026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MAC",
      "code_information": [
        {
          "code": "3598027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LAPAROSCOPIC STR 2190J",
      "code_information": [
        {
          "code": "3598116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-POLY OVAL SOFT WIRE",
      "code_information": [
        {
          "code": "3598262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ARTHROGRAM DYNJ07425",
      "code_information": [
        {
          "code": "3598354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 1 VCP741D",
      "code_information": [
        {
          "code": "3598416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NERVE BLOCK 22G HN3S-80",
      "code_information": [
        {
          "code": "3598440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAG-DISP SUCT 10’ 30-5201",
      "code_information": [
        {
          "code": "3598648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1 VASC1346",
      "code_information": [
        {
          "code": "3598865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/63-74\\\" 1146PP",
      "code_information": [
        {
          "code": "3598976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-NASAL VIP1137380",
      "code_information": [
        {
          "code": "3599139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-NASAL VIP1137381",
      "code_information": [
        {
          "code": "3599142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE RENOVARP GIS-29",
      "code_information": [
        {
          "code": "3599229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 17-22CM",
      "code_information": [
        {
          "code": "3599603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 22-25CM",
      "code_information": [
        {
          "code": "3599604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 25-29CM",
      "code_information": [
        {
          "code": "3599605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 29-36CM",
      "code_information": [
        {
          "code": "3599606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 240014",
      "code_information": [
        {
          "code": "3599773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SSL",
      "code_information": [
        {
          "code": "3600225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1MSL",
      "code_information": [
        {
          "code": "3600226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1LSL",
      "code_information": [
        {
          "code": "3600227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL WIDE EVO1WSL",
      "code_information": [
        {
          "code": "3600228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2SSL",
      "code_information": [
        {
          "code": "3600230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2MSL",
      "code_information": [
        {
          "code": "3600231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2LSL",
      "code_information": [
        {
          "code": "3600232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CN 10MM HEX P45-940-0001",
      "code_information": [
        {
          "code": "3600608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-JTIP .025X33CM",
      "code_information": [
        {
          "code": "3600780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP726D",
      "code_information": [
        {
          "code": "3601389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SEDLINE RD",
      "code_information": [
        {
          "code": "3601706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMP SENSING 16FR 119216",
      "code_information": [
        {
          "code": "3601726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PREM CS006",
      "code_information": [
        {
          "code": "3601999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 0 VCPP31D",
      "code_information": [
        {
          "code": "3602463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-INSTRUMENT T50106",
      "code_information": [
        {
          "code": "3603056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63447",
      "code_information": [
        {
          "code": "3603065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63446",
      "code_information": [
        {
          "code": "3603066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63445",
      "code_information": [
        {
          "code": "3603067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE PMITCSG",
      "code_information": [
        {
          "code": "3603191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3603332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-BIOPSY ORT 27550ZAG/10",
      "code_information": [
        {
          "code": "3603541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG GOLD NR30001010",
      "code_information": [
        {
          "code": "3603912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NOMOLINE LH AIRWAY ADAPTER",
      "code_information": [
        {
          "code": "3603959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED W/ PEEP VALVE",
      "code_information": [
        {
          "code": "3603963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADULT W/ PEEP VAL",
      "code_information": [
        {
          "code": "3603964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION C2202",
      "code_information": [
        {
          "code": "3603996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP840D",
      "code_information": [
        {
          "code": "3604214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROVOX-DILATOR 8341",
      "code_information": [
        {
          "code": "3604745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PERFUSION PUMP 6320",
      "code_information": [
        {
          "code": "3604835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION 120MM",
      "code_information": [
        {
          "code": "3604953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-TRANSDUCER     K11-00096",
      "code_information": [
        {
          "code": "3820165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMPSENSING 16FR   117416",
      "code_information": [
        {
          "code": "3822997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL 4FR 20CM G02366",
      "code_information": [
        {
          "code": "3823450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY          000109",
      "code_information": [
        {
          "code": "4820900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION 16G",
      "code_information": [
        {
          "code": "4825435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-VASCULAR 6MM X 7MM X 5FR",
      "code_information": [
        {
          "code": "1415480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-ANASTOCLIP LARGE 15CM",
      "code_information": [
        {
          "code": "3000773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-PASSER            8591-38",
      "code_information": [
        {
          "code": "3006601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE TISSUE REMOVAL",
      "code_information": [
        {
          "code": "3010310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED ASNIS III",
      "code_information": [
        {
          "code": "3012111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.5MM  702450",
      "code_information": [
        {
          "code": "3012114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST ASNIS III 6.5MM",
      "code_information": [
        {
          "code": "3012151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-HELI-FX            SG-64",
      "code_information": [
        {
          "code": "3016110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE EMG 8050015",
      "code_information": [
        {
          "code": "3022950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAK-CONFIDENCE PLUS",
      "code_information": [
        {
          "code": "3029292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARTHREX ANGEL BMC",
      "code_information": [
        {
          "code": "3058674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 8MMX24CM",
      "code_information": [
        {
          "code": "3058757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 6MMX17CM",
      "code_information": [
        {
          "code": "3058758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 4MMX7CM",
      "code_information": [
        {
          "code": "3058776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MM X xCM",
      "code_information": [
        {
          "code": "3058777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 6MM X xxCM",
      "code_information": [
        {
          "code": "3058840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 CX ALL",
      "code_information": [
        {
          "code": "3058847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MMX15CM",
      "code_information": [
        {
          "code": "3058884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-VERTEX DRILL 2.4MM",
      "code_information": [
        {
          "code": "3059197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-CAROTID ALL     2000-00s",
      "code_information": [
        {
          "code": "3079680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-INTERNAL EEA   EEAXL25",
      "code_information": [
        {
          "code": "3081425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-TVT DEVICE .5\\\"X18\\\" 810041",
      "code_information": [
        {
          "code": "3083229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EMBLEM TUNNELING 4711",
      "code_information": [
        {
          "code": "3084601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-PROGEL PGPS002",
      "code_information": [
        {
          "code": "3091508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER XPEEDA AC-1000729",
      "code_information": [
        {
          "code": "3526375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSSEPTAL NTK-711-8545",
      "code_information": [
        {
          "code": "3527245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 03.033.004",
      "code_information": [
        {
          "code": "3527874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-APEX 11CM 5500-25B-114",
      "code_information": [
        {
          "code": "3527983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-FEMORAL AUG SZ6 154906002",
      "code_information": [
        {
          "code": "3549097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-SPIN ACCESS INS-5900",
      "code_information": [
        {
          "code": "3550000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-INSERTER",
      "code_information": [
        {
          "code": "3550237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-VASC 14X7MM SBT1402D",
      "code_information": [
        {
          "code": "3550693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER ELEVATE 8340155",
      "code_information": [
        {
          "code": "3559412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8013090",
      "code_information": [
        {
          "code": "3559559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-9WX7L AR-8717-0907",
      "code_information": [
        {
          "code": "3598104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER SM 4934-8-100",
      "code_information": [
        {
          "code": "3600215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7FR 4",
      "code_information": [
        {
          "code": "3600789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7F 34",
      "code_information": [
        {
          "code": "3600790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX 45MM 227445500",
      "code_information": [
        {
          "code": "3600946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PREP 4.2MM 0909-100-042",
      "code_information": [
        {
          "code": "3601029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EXP 4.2MM 0909-200-042",
      "code_information": [
        {
          "code": "3601030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-16 HLW 03.037.004S",
      "code_information": [
        {
          "code": "3601121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER MD 4934-8-140",
      "code_information": [
        {
          "code": "3601242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOCLOT EPK2303-01",
      "code_information": [
        {
          "code": "3601392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AUX CBL PLT 94-1500-04-S",
      "code_information": [
        {
          "code": "3601589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-DEBRIDEMENT DDBK02",
      "code_information": [
        {
          "code": "3601755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-GUIDE VDR 80-0049",
      "code_information": [
        {
          "code": "3602651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-DELIVERY STRBL-14F-075",
      "code_information": [
        {
          "code": "3603178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AO CONN P65-001-0001-SK",
      "code_information": [
        {
          "code": "3603438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM RC P01-DWL-0915",
      "code_information": [
        {
          "code": "3604386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7.5FR",
      "code_information": [
        {
          "code": "3827764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBEROPTIC BALLOON 8.0FR",
      "code_information": [
        {
          "code": "3827765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X34MM 657734",
      "code_information": [
        {
          "code": "3900153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X36MM 657736",
      "code_information": [
        {
          "code": "3900154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X38MM 657738",
      "code_information": [
        {
          "code": "3900155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X9MM 657709",
      "code_information": [
        {
          "code": "3900160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X11MM 656111",
      "code_information": [
        {
          "code": "3900161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X13MM 656113",
      "code_information": [
        {
          "code": "3900162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
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          "maximum": 4130.3402,
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          ]
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    },
    {
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        },
        {
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        {
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        {
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    {
      "description": "SCREW-BONE 2.3X24MM 663824",
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        },
        {
          "code": "0270",
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        }
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              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X26MM 663826",
      "code_information": [
        {
          "code": "3900208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/1.7MM 57-05202",
      "code_information": [
        {
          "code": "3900368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/LT 57-05221",
      "code_information": [
        {
          "code": "3900369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/RT 57-05220",
      "code_information": [
        {
          "code": "3900370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 6H/1.7MM 57-05240",
      "code_information": [
        {
          "code": "3900371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 10H/1.7 57-05262",
      "code_information": [
        {
          "code": "3900372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 7H/1.7MM 57-05260",
      "code_information": [
        {
          "code": "3900373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Y 7H/1.7MM 57-05270",
      "code_information": [
        {
          "code": "3900374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 5H/2.3MM 57-13405",
      "code_information": [
        {
          "code": "3900381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/2.3MM 57-13408",
      "code_information": [
        {
          "code": "3900382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 8H/2.3MM 57-13410",
      "code_information": [
        {
          "code": "3900383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-13421",
      "code_information": [
        {
          "code": "3900385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13440",
      "code_information": [
        {
          "code": "3900386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13450",
      "code_information": [
        {
          "code": "3900387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13906",
      "code_information": [
        {
          "code": "3900389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 2H/23MM 626672",
      "code_information": [
        {
          "code": "3900390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 3H/35MM",
      "code_information": [
        {
          "code": "3900391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 8.0MM LG AO",
      "code_information": [
        {
          "code": "3900392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/2.3 57-10190",
      "code_information": [
        {
          "code": "3900393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/RT 57-10120",
      "code_information": [
        {
          "code": "3900395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3MM 57-10140",
      "code_information": [
        {
          "code": "3900396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-SCREW F/ 2.7MM AO 703899",
      "code_information": [
        {
          "code": "3900399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-SCREW F/ 3.5MM AO 703898",
      "code_information": [
        {
          "code": "3900400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 4H/47MM",
      "code_information": [
        {
          "code": "3900401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 4H 629504",
      "code_information": [
        {
          "code": "3900402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 4H 629544",
      "code_information": [
        {
          "code": "3900403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2+2H/1.7 57-05297",
      "code_information": [
        {
          "code": "3900406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/1.7 57-052920",
      "code_information": [
        {
          "code": "3900407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7 57-05295",
      "code_information": [
        {
          "code": "3900410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/1.7/LT 57-05283",
      "code_information": [
        {
          "code": "3900411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/2.3MM 57-10402",
      "code_information": [
        {
          "code": "3900414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-10420",
      "code_information": [
        {
          "code": "3900417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10421",
      "code_information": [
        {
          "code": "3900418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10460",
      "code_information": [
        {
          "code": "3900420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP Y 6H/2.3MM 57-10470",
      "code_information": [
        {
          "code": "3900421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3799.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE    16G X 12.5",
      "code_information": [
        {
          "code": "1410723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANTENNA-PROGRAMMER       37092",
      "code_information": [
        {
          "code": "3000651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        310.111",
      "code_information": [
        {
          "code": "3002241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2       AR-8944-22",
      "code_information": [
        {
          "code": "3002251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0          316.396",
      "code_information": [
        {
          "code": "3002271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM         310.31",
      "code_information": [
        {
          "code": "3002300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM         310.11",
      "code_information": [
        {
          "code": "3002784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM         310.26",
      "code_information": [
        {
          "code": "3002788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM         310.44",
      "code_information": [
        {
          "code": "3002798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DISSECT ELECTRODE 139330",
      "code_information": [
        {
          "code": "3002955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW             511.9xxS",
      "code_information": [
        {
          "code": "3003266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS  03.000.3xxS",
      "code_information": [
        {
          "code": "3003268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 532.066S",
      "code_information": [
        {
          "code": "3003293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 225 ML04253",
      "code_information": [
        {
          "code": "3003420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 125ML 04251",
      "code_information": [
        {
          "code": "3003421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 4MM PAL-404LLB",
      "code_information": [
        {
          "code": "3004044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-304LLB",
      "code_information": [
        {
          "code": "3004046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO PAL-304LM",
      "code_information": [
        {
          "code": "3004053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPORT II PAL-406LS",
      "code_information": [
        {
          "code": "3004250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHOLANGIOGRAM       C100",
      "code_information": [
        {
          "code": "3005220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR TITANIUM  FV012T",
      "code_information": [
        {
          "code": "3009771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3          316.402",
      "code_information": [
        {
          "code": "3012305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM AR-4160-35",
      "code_information": [
        {
          "code": "3012347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.141",
      "code_information": [
        {
          "code": "3012354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 310.25",
      "code_information": [
        {
          "code": "3012405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-558",
      "code_information": [
        {
          "code": "3012475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 3.2X300MM",
      "code_information": [
        {
          "code": "3014238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUGE 03.804.5x",
      "code_information": [
        {
          "code": "3020805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PREP     546102000",
      "code_information": [
        {
          "code": "3020926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 24FR      880-213",
      "code_information": [
        {
          "code": "3021819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE WATER",
      "code_information": [
        {
          "code": "3023171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE  2839-xx-xxx",
      "code_information": [
        {
          "code": "3027302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTROSURG 134006",
      "code_information": [
        {
          "code": "3029511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-TRIMANO BEACH CHAIR",
      "code_information": [
        {
          "code": "3034325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL  1.5MM W/8.0MM STOP",
      "code_information": [
        {
          "code": "3058520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM CALIBRATED",
      "code_information": [
        {
          "code": "3058937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 19 G05880",
      "code_information": [
        {
          "code": "3058996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8943-",
      "code_information": [
        {
          "code": "3059000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-AIRWAY EXCH 8F G07833",
      "code_information": [
        {
          "code": "3059157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 11 G06732",
      "code_information": [
        {
          "code": "3059264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-4.5MM INCISOR PLUS",
      "code_information": [
        {
          "code": "3060481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 5MM          CB5LT",
      "code_information": [
        {
          "code": "3079768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DOYLE II AIRWY 15-24055",
      "code_information": [
        {
          "code": "3080045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-                TLC-55",
      "code_information": [
        {
          "code": "3081528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30GRN     TX30G",
      "code_information": [
        {
          "code": "3081555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30BL      TX30B",
      "code_information": [
        {
          "code": "3081557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-8916-14",
      "code_information": [
        {
          "code": "3087940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CALIBRATED DRILL 2.5",
      "code_information": [
        {
          "code": "3087942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER   60-6085-20x",
      "code_information": [
        {
          "code": "3145100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER     G3640x",
      "code_information": [
        {
          "code": "3509540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3521005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BACK TABLE     DYNJ31777A",
      "code_information": [
        {
          "code": "3526152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-C-SECTION      DYNJ31780C",
      "code_information": [
        {
          "code": "3526153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VASCULAR LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3526426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSDUCER TRUWAVE PX272",
      "code_information": [
        {
          "code": "3526526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE UNTHREAD 2X200MM",
      "code_information": [
        {
          "code": "3526988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 16/18 FR 96551",
      "code_information": [
        {
          "code": "3527178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET",
      "code_information": [
        {
          "code": "3527263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SOMA ADULT SAFB-SM/USA",
      "code_information": [
        {
          "code": "3527866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DELIVERY NAVIFLEX 7FR.",
      "code_information": [
        {
          "code": "3527884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EPG CONNECTOR 53912D",
      "code_information": [
        {
          "code": "3549025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLOWSAFE II",
      "code_information": [
        {
          "code": "3549715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-NAIL 1806-1406S",
      "code_information": [
        {
          "code": "3549850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VORTRAN RESUSCITATION",
      "code_information": [
        {
          "code": "3550702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2020-00-335",
      "code_information": [
        {
          "code": "3550711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-DRILLING COMP EL-DTS",
      "code_information": [
        {
          "code": "3550764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SPEED FEMORAL AE-1605",
      "code_information": [
        {
          "code": "3550845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SELECTOR-VEIN 57538CSV-WOR",
      "code_information": [
        {
          "code": "3559121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-INSTRUMENT 0306-531-000",
      "code_information": [
        {
          "code": "3559266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-EXCELSIUS ARM 6143.2001S",
      "code_information": [
        {
          "code": "3559497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-MONITOR 6143.2003S",
      "code_information": [
        {
          "code": "3559498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-TRANSFUSION EXCHANGE",
      "code_information": [
        {
          "code": "3571501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR CARE XL MULTI-USE",
      "code_information": [
        {
          "code": "3598079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/KNEE WRAP",
      "code_information": [
        {
          "code": "3598180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/SHOULDER WRAP",
      "code_information": [
        {
          "code": "3598181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 94725",
      "code_information": [
        {
          "code": "3598197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE MIXTURE",
      "code_information": [
        {
          "code": "3598303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTYCORE 16GX7.5CM",
      "code_information": [
        {
          "code": "3598364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELBOW TRIMANO AR-1646",
      "code_information": [
        {
          "code": "3598377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN 1.7/2.0 DRILL 45-20011",
      "code_information": [
        {
          "code": "3598514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 10ML GIS-59",
      "code_information": [
        {
          "code": "3599411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.1X150MM 03.333.001",
      "code_information": [
        {
          "code": "3599532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPAP BUBBLE MR290 CHAMBER",
      "code_information": [
        {
          "code": "3599616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.5X150MM QC 03.133.109",
      "code_information": [
        {
          "code": "3599727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-90° SAG 2296-003-109S2",
      "code_information": [
        {
          "code": "3599964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3600835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 16H 76-9103",
      "code_information": [
        {
          "code": "3600836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 24H 76-9104",
      "code_information": [
        {
          "code": "3600837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB NTHRD AR-18800-11",
      "code_information": [
        {
          "code": "3600896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE STER 03.804.519S",
      "code_information": [
        {
          "code": "3600903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G ACCESS 03.804.517S",
      "code_information": [
        {
          "code": "3600911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X330 S0100-000",
      "code_information": [
        {
          "code": "3601632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FISTULA FUNNEL",
      "code_information": [
        {
          "code": "3601648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE BVT 03.804.520S",
      "code_information": [
        {
          "code": "3601878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE RUNTHRU 180 25-5211",
      "code_information": [
        {
          "code": "3601952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE ARTERIAL ART356",
      "code_information": [
        {
          "code": "3602029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION PD-IT",
      "code_information": [
        {
          "code": "3602078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OIL-BIENAIR LUBRIFLUID 1600064",
      "code_information": [
        {
          "code": "3602105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE 16G X 16.5",
      "code_information": [
        {
          "code": "3602125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300S NTHRD 702463S",
      "code_information": [
        {
          "code": "3602409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL",
      "code_information": [
        {
          "code": "3602464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREDED AR-18800-11T",
      "code_information": [
        {
          "code": "3602495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-5 MREYE G36405",
      "code_information": [
        {
          "code": "3602688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-3 MREYE G42419",
      "code_information": [
        {
          "code": "3602689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3602820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G BVL 0306-331-000",
      "code_information": [
        {
          "code": "3603302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE -.9MM AR-7524C",
      "code_information": [
        {
          "code": "3604464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DBL 4X30/10 PAL-405LL",
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        {
          "code": "3604617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-8x30/8 PAL-402LL",
      "code_information": [
        {
          "code": "3604619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GLIDESHEATH RM*ES6J10HAT",
      "code_information": [
        {
          "code": "3824107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X55MM 657055",
      "code_information": [
        {
          "code": "3900358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION RX  M00566670",
      "code_information": [
        {
          "code": "4822473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-COAXIAL BIPSY 946x-VC-006",
      "code_information": [
        {
          "code": "1416380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OPTIFIX-ABSORBABLE 0113126",
      "code_information": [
        {
          "code": "3000012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 7.3     310.495",
      "code_information": [
        {
          "code": "3002265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT LARYNGEAL 4MM",
      "code_information": [
        {
          "code": "3003289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OXFORD SAW 506298",
      "code_information": [
        {
          "code": "3003294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-TUR PK           786500",
      "code_information": [
        {
          "code": "3003816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 96370-023",
      "code_information": [
        {
          "code": "3004233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-020",
      "code_information": [
        {
          "code": "3008516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 11X280       357.404",
      "code_information": [
        {
          "code": "3012311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX     2274-25-500",
      "code_information": [
        {
          "code": "3012384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 7.0X3.2",
      "code_information": [
        {
          "code": "3012900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-HALO CUTTING HACF-0533",
      "code_information": [
        {
          "code": "3013285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EVICEL FIBRIN SEALANT 3905",
      "code_information": [
        {
          "code": "3021100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-SEALER 5MM     LF1637",
      "code_information": [
        {
          "code": "3021738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-TUR       784415 & 784515",
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        {
          "code": "3021867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3021877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NAVIGATED PAK9733498NAV",
      "code_information": [
        {
          "code": "3027426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-OPEN HEART     DYNJ32033A",
      "code_information": [
        {
          "code": "3029235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ULTRASOUND ALL SZ 840-7s",
      "code_information": [
        {
          "code": "3034490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS EPIDUR VEIN",
      "code_information": [
        {
          "code": "3044898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DEEP SCROTAL RETRACTION",
      "code_information": [
        {
          "code": "3083072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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      ],
      "service_type": "CDM"
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    {
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        {
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    {
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    {
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    {
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    {
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    {
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    {
      "description": "KNIFE-UNIV SONIC 5450815114",
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            }
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        }
      ],
      "service_type": "CDM"
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    {
      "description": "PROBE-VENTRIC PACING    D98100",
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        {
          "code": "0270",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.915S",
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        {
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      "standard_charges": [
        {
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-7.0 CANNULATED 400146",
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        },
        {
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        }
      ],
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        {
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSSEPTAL RF",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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      ],
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    },
    {
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      ],
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    },
    {
      "description": "BIT-CANN 10MM 03.037.021",
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 550 AC-10030120",
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        },
        {
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRING 675.705S",
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        },
        {
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          "type": "RC"
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      ],
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        {
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            {
              "payer_name": "Anthem",
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    },
    {
      "description": "PROBE-8\\\" INSULATED 675.706S",
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        },
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    },
    {
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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        }
      ],
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    },
    {
      "description": "SYSTEM-ILLUMINATION 698.605S",
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        },
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      ],
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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        }
      ],
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    },
    {
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        },
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "HAMMER-SLAP 694.008",
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        },
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        }
      ],
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        {
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              "payer_name": "Anthem",
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      ],
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    },
    {
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        },
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        }
      ],
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        {
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              "payer_name": "Anthem",
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        }
      ],
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    },
    {
      "description": "AWL-HELIX 6.5 ADVANCE 222313",
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        },
        {
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        }
      ],
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        {
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        }
      ],
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    },
    {
      "description": "DRILL-TWIST 2.7X160 A-8004.01",
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        },
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        }
      ],
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        {
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              "payer_name": "Anthem",
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      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DRIVER 4 CANN A-8004.11",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-LIGASURE 37CM LF1944",
      "code_information": [
        {
          "code": "3559070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 16MM XFR004216",
      "code_information": [
        {
          "code": "3559091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-WIRELESS CELL EX1151",
      "code_information": [
        {
          "code": "3559233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-15MM/3.5OS 9159.3035",
      "code_information": [
        {
          "code": "3559597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 2.0",
      "code_information": [
        {
          "code": "3559670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3566817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40B GCS40B",
      "code_information": [
        {
          "code": "3598106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM 03.333.103",
      "code_information": [
        {
          "code": "3598147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-STRT TIP BAYON 1590-01",
      "code_information": [
        {
          "code": "3598218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH",
      "code_information": [
        {
          "code": "3598452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SUREFORM 60 480460",
      "code_information": [
        {
          "code": "3598611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 27CM APYX-27-TP",
      "code_information": [
        {
          "code": "3598956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-1X10.5MM BI 632.678S",
      "code_information": [
        {
          "code": "3599051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERCLAGE AR-7268",
      "code_information": [
        {
          "code": "3599170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-CERCLAGE AR-7268T",
      "code_information": [
        {
          "code": "3599171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM 03.333.102",
      "code_information": [
        {
          "code": "3599533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-NANO 125MM AR-3210-0043",
      "code_information": [
        {
          "code": "3600299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-MINI COREDX M00515220",
      "code_information": [
        {
          "code": "3600762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR CVD GCS40G",
      "code_information": [
        {
          "code": "3600838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-LARGE DV2012-LF",
      "code_information": [
        {
          "code": "3600953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-8-13MM P99-110-0813",
      "code_information": [
        {
          "code": "3601104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-UNIVERSAL PAD ARTICGEL",
      "code_information": [
        {
          "code": "3601634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIBER OPTIC PTEYE-1",
      "code_information": [
        {
          "code": "3602127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE 45\\\" HAR745",
      "code_information": [
        {
          "code": "3602909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE HAR736",
      "code_information": [
        {
          "code": "3602910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA 13CM PRE1101US",
      "code_information": [
        {
          "code": "3603187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 11G NN-1000",
      "code_information": [
        {
          "code": "3603528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 13G NN-1001",
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        {
          "code": "3603586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY MAX M00546470",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL M00546550",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-RETRIEVAL M00546560",
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        {
          "code": "3603813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-8MM/CV SF30 488530",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY 115CM G48240",
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        {
          "code": "3603969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 25 LS96555-025",
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        {
          "code": "3604574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SUPERLOOP TUR 784415",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-AO T8 93MM 542011",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-SD T20 93MM 542066",
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        {
          "code": "3604973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BG 6MM ABS-8000-06",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-3 SYS REFERENCE   CREFP6",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X6MM 656306",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X70MM 656370",
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        {
          "code": "3900340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/178MM/RT 627490",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/173MM/RT 627338",
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        {
          "code": "3900605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DEC BRIDGE 8H/RT 628068",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 6H/LT 628146",
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        {
          "code": "3900607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/151MM/RT 627238",
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          "code": "3900629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 6H/166MM/LT 627606",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 6H/166MM/RT 627636",
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          "code": "3900632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 12H/202MM/RT 627242",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 8H/202MM/LT 627608",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 12H/274MM/RT 627642",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAM SB3",
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          "code": "4821711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 704.76,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2260.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYN            ALLSZs",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.9601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC PED 10FR    8010",
      "code_information": [
        {
          "code": "1102034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 12FR PEDS   8012",
      "code_information": [
        {
          "code": "1102046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.5711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK BABY",
      "code_information": [
        {
          "code": "1102135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC 3-LUMEN PWR INJ SAFET",
      "code_information": [
        {
          "code": "1110365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 516.6696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH LUMEN 4FR    AK-14402",
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        {
          "code": "1110376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "1113245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS          G04153",
      "code_information": [
        {
          "code": "1113258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 291.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-FOREIGN BODY   FB-5000",
      "code_information": [
        {
          "code": "1115735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 837,
          "minimum": 175.77,
          "maximum": 612.8514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.8233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEONATE TUBE RESV",
      "code_information": [
        {
          "code": "1115845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATHETER CRICOTHYROTOMY",
      "code_information": [
        {
          "code": "1118135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1639,
          "minimum": 344.19,
          "maximum": 1200.0758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1104.0697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-HANGING CAST LG 1180LPP",
      "code_information": [
        {
          "code": "1118520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "1118720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "1118735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "#1855G 5-0 ETHILON PC-1",
      "code_information": [
        {
          "code": "1118792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 49,
          "minimum": 10.29,
          "maximum": 35.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 33.0076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EVAC/DRAIN 1-BTL  62287",
      "code_information": [
        {
          "code": "1118801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED       8CFN",
      "code_information": [
        {
          "code": "1118955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 339,
          "minimum": 71.19,
          "maximum": 248.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 228.3585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "1119001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 41,
          "minimum": 8.61,
          "maximum": 30.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 27.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "1119800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 48,
          "minimum": 10.08,
          "maximum": 35.1456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 32.334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-15      G00012",
      "code_information": [
        {
          "code": "1410067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINL 22X20     G03542",
      "code_information": [
        {
          "code": "1410472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 256,
          "minimum": 53.76,
          "maximum": 187.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.4477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CUSTOM WASTE BAG",
      "code_information": [
        {
          "code": "1410792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.9677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-INDIGO W/TUBING IAPS2",
      "code_information": [
        {
          "code": "1410803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1627.4756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INFUSION MRI          1056",
      "code_information": [
        {
          "code": "1410839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE ADAPTER MRI   1057",
      "code_information": [
        {
          "code": "1410840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.8083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18G 20CM   G01047",
      "code_information": [
        {
          "code": "1410918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.4326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1411090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18-15      G03954",
      "code_information": [
        {
          "code": "1411193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.1764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MONOPTY 18X10    121810",
      "code_information": [
        {
          "code": "1411612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 203.4344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JAR-COPLIN PP STAIN     S90130",
      "code_information": [
        {
          "code": "1411903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION     CID-20-30",
      "code_information": [
        {
          "code": "1412310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 734,
          "minimum": 154.14,
          "maximum": 537.4348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 494.44,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE .010-.038   TD01",
      "code_information": [
        {
          "code": "1412325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-STAYFIX SMALL    680-ME",
      "code_information": [
        {
          "code": "1412330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL IV 6FR   48-152",
      "code_information": [
        {
          "code": "1412380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL ALL 48-100's",
      "code_information": [
        {
          "code": "1412394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX ALL SZ",
      "code_information": [
        {
          "code": "1413165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.1118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX ALL SZ",
      "code_information": [
        {
          "code": "1413170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 523,
          "minimum": 109.83,
          "maximum": 382.9406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 352.3054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-20      G00810",
      "code_information": [
        {
          "code": "1414825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN ALL SZS G01xxx",
      "code_information": [
        {
          "code": "1414845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY ALL SZS",
      "code_information": [
        {
          "code": "1414866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 286.9638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-10      G01112",
      "code_information": [
        {
          "code": "1414935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "1414990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 153.5863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X     C20xxA",
      "code_information": [
        {
          "code": "1414995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.0929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-IV SILVERSITE 1X7MM",
      "code_information": [
        {
          "code": "1415449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT GASTRO INITIAL SM",
      "code_information": [
        {
          "code": "1415943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 987,
          "minimum": 207.27,
          "maximum": 722.6814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 664.8669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-150 ML ILLUMENA 900103",
      "code_information": [
        {
          "code": "1416100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGIOGRAPHY    MCBK001-07",
      "code_information": [
        {
          "code": "1416236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 783,
          "minimum": 164.43,
          "maximum": 573.3126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 527.4476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22FR   0250-22",
      "code_information": [
        {
          "code": "1416370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENTUIT THRIVE 14F",
      "code_information": [
        {
          "code": "1416371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 713,
          "minimum": 149.73,
          "maximum": 522.0586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 480.2939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-INDIGO             IST3",
      "code_information": [
        {
          "code": "1416377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2920,
          "minimum": 613.2,
          "maximum": 2138.024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1966.9821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1419101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX11C",
      "code_information": [
        {
          "code": "1419112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX15C",
      "code_information": [
        {
          "code": "1419113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 20GX15C",
      "code_information": [
        {
          "code": "1419114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX11C",
      "code_information": [
        {
          "code": "1419116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX15C",
      "code_information": [
        {
          "code": "1419118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 601,
          "minimum": 126.21,
          "maximum": 440.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 404.848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX20C",
      "code_information": [
        {
          "code": "1419119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 601,
          "minimum": 126.21,
          "maximum": 440.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 404.848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY  20GX11C",
      "code_information": [
        {
          "code": "1419293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 451,
          "minimum": 94.71,
          "maximum": 330.2222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.8044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-BIOPSY EVIVA 9G",
      "code_information": [
        {
          "code": "1495152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-TISSUE ATEC        TF-1",
      "code_information": [
        {
          "code": "1495228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-EVIVA STX   0913-12T",
      "code_information": [
        {
          "code": "1495304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE MULTICARE  MME-00347",
      "code_information": [
        {
          "code": "1495418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC",
      "code_information": [
        {
          "code": "2395902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC 50MM",
      "code_information": [
        {
          "code": "2395904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAT-SURGISAFE ABSORBANT FLOOR",
      "code_information": [
        {
          "code": "3000001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 323,
          "minimum": 67.83,
          "maximum": 236.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 217.5806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-FULL RADIUS 5.5MM",
      "code_information": [
        {
          "code": "3000006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO               2C4040",
      "code_information": [
        {
          "code": "3000090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CONFIDENCE 2839-99-002",
      "code_information": [
        {
          "code": "3000520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-HEMOSTASES  HC0001",
      "code_information": [
        {
          "code": "3000742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1597,
          "minimum": 335.37,
          "maximum": 1169.3234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1075.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-CLIP MED/LG 20 SMC",
      "code_information": [
        {
          "code": "3000753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 678.3394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP PK AM0004",
      "code_information": [
        {
          "code": "3000760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP    AM0005",
      "code_information": [
        {
          "code": "3000762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.5597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP  DISP   MCM20",
      "code_information": [
        {
          "code": "3000765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 518,
          "minimum": 108.78,
          "maximum": 379.2796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 348.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP LARGE MCL20",
      "code_information": [
        {
          "code": "3000766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 553,
          "minimum": 116.13,
          "maximum": 404.9066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 372.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP SM MCS20",
      "code_information": [
        {
          "code": "3000767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 569,
          "minimum": 119.49,
          "maximum": 416.6218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 383.2921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-AUTOMATIC 5MM AE05ML",
      "code_information": [
        {
          "code": "3000770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 872.3431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGAMAX 5MM CLIP EL5ML",
      "code_information": [
        {
          "code": "3000771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1389,
          "minimum": 291.69,
          "maximum": 1017.0258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 935.6637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSISTANT-SUTURE 5MM     SW100",
      "code_information": [
        {
          "code": "3000865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1311,
          "minimum": 275.31,
          "maximum": 959.9142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 883.1211,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-ANCHOR TISSUE ROBOTIC",
      "code_information": [
        {
          "code": "3001135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 437.182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-ENDOPOUCH 10MM POUCH",
      "code_information": [
        {
          "code": "3001190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-DISPOSA 3MM       DBL-311",
      "code_information": [
        {
          "code": "3001371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IPRISM IPC05",
      "code_information": [
        {
          "code": "3001669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAR-TIBIAL LOCKING      141205",
      "code_information": [
        {
          "code": "3002092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1493,
          "minimum": 313.53,
          "maximum": 1093.1746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1005.7206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 1.9X120 390-201",
      "code_information": [
        {
          "code": "3002152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1576,
          "minimum": 330.96,
          "maximum": 1153.9472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1061.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOFILTER-ASP FLTR",
      "code_information": [
        {
          "code": "3002210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 508,
          "minimum": 106.68,
          "maximum": 371.9576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CEMENT-COMPACT VACUUM",
      "code_information": [
        {
          "code": "3002214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.7529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           315.48",
      "code_information": [
        {
          "code": "3002244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.2      310.65",
      "code_information": [
        {
          "code": "3002246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MINI DRILL AT2M-1813",
      "code_information": [
        {
          "code": "3002257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1465.1322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145   03.010.104",
      "code_information": [
        {
          "code": "3002260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1668,
          "minimum": 350.28,
          "maximum": 1221.3096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1123.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    351.27",
      "code_information": [
        {
          "code": "3002270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3542,
          "minimum": 743.82,
          "maximum": 2593.4524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2385.9762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM      03.010.036",
      "code_information": [
        {
          "code": "3002274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3373,
          "minimum": 708.33,
          "maximum": 2469.7106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2272.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.060",
      "code_information": [
        {
          "code": "3002289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2190,
          "minimum": 459.9,
          "maximum": 1603.518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1475.2366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5           310.23",
      "code_information": [
        {
          "code": "3002291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 937,
          "minimum": 196.77,
          "maximum": 686.0714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 631.1857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM         310.19",
      "code_information": [
        {
          "code": "3002294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 949,
          "minimum": 199.29,
          "maximum": 694.8578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 639.2692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MMX150MM  511.417",
      "code_information": [
        {
          "code": "3002302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1642,
          "minimum": 344.82,
          "maximum": 1202.2724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1106.0906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2 ALL 1806-4200s",
      "code_information": [
        {
          "code": "3002305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1134,
          "minimum": 238.14,
          "maximum": 830.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 763.8896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X180MM 1806-4270S",
      "code_information": [
        {
          "code": "3002306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 819.1268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR        5091-206",
      "code_information": [
        {
          "code": "3002318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR",
      "code_information": [
        {
          "code": "3002324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-STEP DRILL         357.403",
      "code_information": [
        {
          "code": "3002361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3578,
          "minimum": 751.38,
          "maximum": 2619.8116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2410.2267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.4     310.530",
      "code_information": [
        {
          "code": "3002365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1282,
          "minimum": 269.22,
          "maximum": 938.6804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 863.586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           1806-5020S",
      "code_information": [
        {
          "code": "3002379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1219,
          "minimum": 255.99,
          "maximum": 892.5518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 821.1477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM        388.394",
      "code_information": [
        {
          "code": "3002383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         60-20385",
      "code_information": [
        {
          "code": "3002391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 742.3336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 03.113.024",
      "code_information": [
        {
          "code": "3002394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1440,
          "minimum": 302.4,
          "maximum": 1054.368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 970.0186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 03.113.023",
      "code_information": [
        {
          "code": "3002399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1440,
          "minimum": 302.4,
          "maximum": 1054.368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 970.0186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM 703542",
      "code_information": [
        {
          "code": "3002400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 864.9332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3MM 703541",
      "code_information": [
        {
          "code": "3002402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1335,
          "minimum": 280.35,
          "maximum": 977.487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 899.288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5085-2-032",
      "code_information": [
        {
          "code": "3002403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM 5085-2-040",
      "code_information": [
        {
          "code": "3002410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 1.7MM",
      "code_information": [
        {
          "code": "3002760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1755,
          "minimum": 368.55,
          "maximum": 1285.011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1182.2101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO        1806-5000S",
      "code_information": [
        {
          "code": "3002772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1103,
          "minimum": 231.63,
          "maximum": 807.6166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 743.0073,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM     03.010.061",
      "code_information": [
        {
          "code": "3002776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2190,
          "minimum": 459.9,
          "maximum": 1603.518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1475.2366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM    03.010.101S",
      "code_information": [
        {
          "code": "3002777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1465.1322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.6x",
      "code_information": [
        {
          "code": "3002779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2769,
          "minimum": 581.49,
          "maximum": 2027.4618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1865.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL W/STOP ALL   324.15x",
      "code_information": [
        {
          "code": "3002780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2797,
          "minimum": 587.37,
          "maximum": 2047.9634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1884.1263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.68",
      "code_information": [
        {
          "code": "3002782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2977,
          "minimum": 625.17,
          "maximum": 2179.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2005.3786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 17MM    357.394",
      "code_information": [
        {
          "code": "3002785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4976,
          "minimum": 1044.96,
          "maximum": 3643.4272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3351.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM         700347",
      "code_information": [
        {
          "code": "3002791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1337,
          "minimum": 280.77,
          "maximum": 978.9514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 900.6353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1MM         702742",
      "code_information": [
        {
          "code": "3002793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1019,
          "minimum": 213.99,
          "maximum": 746.1118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 686.4229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X110MM     310.35",
      "code_information": [
        {
          "code": "3002794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 921,
          "minimum": 193.41,
          "maximum": 674.3562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 620.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER MINI       376900",
      "code_information": [
        {
          "code": "3002835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 9-9.5MM 5400-031-xxx",
      "code_information": [
        {
          "code": "3002951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1113,
          "minimum": 233.73,
          "maximum": 814.9386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 749.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EXT ELECTRODE    E1551-6",
      "code_information": [
        {
          "code": "3002959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-TURBINATE INF SB2000SA",
      "code_information": [
        {
          "code": "3002962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1139,
          "minimum": 239.19,
          "maximum": 833.9758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.2577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SERRATED STND SB4000SS",
      "code_information": [
        {
          "code": "3002963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 875.7112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MYRINGOTOMY SPEAR TIP",
      "code_information": [
        {
          "code": "3003112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RAD 40 DEGREE 18-84006HR",
      "code_information": [
        {
          "code": "3003122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1727,
          "minimum": 362.67,
          "maximum": 1264.5094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1163.3486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RADNOID 18-84008",
      "code_information": [
        {
          "code": "3003123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1721,
          "minimum": 361.41,
          "maximum": 1260.1162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1159.3069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RASP SAW       510037113",
      "code_information": [
        {
          "code": "3003127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 746.3754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW MICR 9MM 2296-3-100s",
      "code_information": [
        {
          "code": "3003143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 350.9581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG SAW 9X25 ALL 2296s",
      "code_information": [
        {
          "code": "3003147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 350.9581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 5.5MMX18MM  KM 3-412",
      "code_information": [
        {
          "code": "3003150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW GIGLI ROUND  2808-01",
      "code_information": [
        {
          "code": "3003172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.5597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HEX COATED 2.75   E1450X",
      "code_information": [
        {
          "code": "3003200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-INF TURB 2.0  18-82040HR",
      "code_information": [
        {
          "code": "3003227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2469,
          "minimum": 518.49,
          "maximum": 1807.8018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1663.1777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD DISP   8000-140",
      "code_information": [
        {
          "code": "3003251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 154.2599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90Xxx    05.003.1xxS",
      "code_information": [
        {
          "code": "3003256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 420.3414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380HR",
      "code_information": [
        {
          "code": "3003258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1739,
          "minimum": 365.19,
          "maximum": 1273.2958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1171.4321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380EM",
      "code_information": [
        {
          "code": "3003259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2147.5133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS     519.xxxS",
      "code_information": [
        {
          "code": "3003292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 522.7322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CELL SAVER HI SP   CSP26x",
      "code_information": [
        {
          "code": "3003419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 777,
          "minimum": 163.17,
          "maximum": 568.9194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 523.4058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-SMARTMIX CTS    540176501",
      "code_information": [
        {
          "code": "3003433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-INTERNAL AR-1678-CP",
      "code_information": [
        {
          "code": "3003471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5500,
          "minimum": 1155,
          "maximum": 4027.1,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3704.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-UNIV X-ACT 11-2151-9",
      "code_information": [
        {
          "code": "3003472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 998,
          "minimum": 209.58,
          "maximum": 730.7356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 672.2768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-COLON CYTO        000110",
      "code_information": [
        {
          "code": "3003503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 108.4535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-WHISTLE CLEANING  000101",
      "code_information": [
        {
          "code": "3003605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.5711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT RND 2296-100-421",
      "code_information": [
        {
          "code": "3003756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL CUTTING 5300-010-901",
      "code_information": [
        {
          "code": "3003762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 187.2675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND          277-10-423",
      "code_information": [
        {
          "code": "3003782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND CUT 2.4MM  5091-225",
      "code_information": [
        {
          "code": "3003786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 163.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT 1.6   277-10-xxx",
      "code_information": [
        {
          "code": "3003792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.8349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-WATERMELON      1607-2-35",
      "code_information": [
        {
          "code": "3003805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 420.3414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL   SP-7810",
      "code_information": [
        {
          "code": "3003812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 858.197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 2MM 5820-013-0xx",
      "code_information": [
        {
          "code": "3003829",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 860.2178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND S03.000.009S",
      "code_information": [
        {
          "code": "3003841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 363.757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND 4.0MM    277-10-240",
      "code_information": [
        {
          "code": "3003855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.1916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 5MM     5820-013-050",
      "code_information": [
        {
          "code": "3003856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING BLUE   FL-601-97B",
      "code_information": [
        {
          "code": "3003905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT STERILE MAS PLIF",
      "code_information": [
        {
          "code": "3003914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1921.8493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ARCH 6.5  80320",
      "code_information": [
        {
          "code": "3004042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO DBL 5MM PAL-505LL",
      "code_information": [
        {
          "code": "3004047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY PREMATURE",
      "code_information": [
        {
          "code": "3004048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.4117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY NEONATAL",
      "code_information": [
        {
          "code": "3004049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.4117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERPAY INFANT",
      "code_information": [
        {
          "code": "3004051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.4117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-308LS",
      "code_information": [
        {
          "code": "3004052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 498.4818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CURVED 100MM 20G 10.0M",
      "code_information": [
        {
          "code": "3004190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX FEM TFA-022-25",
      "code_information": [
        {
          "code": "3004225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX       TFA02025",
      "code_information": [
        {
          "code": "3004226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 27FR 96370-027",
      "code_information": [
        {
          "code": "3004235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1777,
          "minimum": 373.17,
          "maximum": 1301.1194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1197.0298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-I-STAT CREATININE",
      "code_information": [
        {
          "code": "3004750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 22FR 30CC      266722",
      "code_information": [
        {
          "code": "3004837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.4592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-5FR RAD PIGTAIL 5RPS110-N",
      "code_information": [
        {
          "code": "3004842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 364,
          "minimum": 76.44,
          "maximum": 266.5208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 245.1991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TACKER DELIVERY OMS-TTS",
      "code_information": [
        {
          "code": "3005077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3218,
          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2167.722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHLOANGIOGRAM   20018-010",
      "code_information": [
        {
          "code": "3005234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 613,
          "minimum": 128.73,
          "maximum": 448.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 412.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 24Fr 5CC 265724",
      "code_information": [
        {
          "code": "3005414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3WAY         73022L",
      "code_information": [
        {
          "code": "3005435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.2106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 34FR-46FR ALL",
      "code_information": [
        {
          "code": "3007230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.9106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 36FR-46FR  TF36460",
      "code_information": [
        {
          "code": "3007235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.9106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP         AA01",
      "code_information": [
        {
          "code": "3007600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-ACU-DISPO      DCFT2",
      "code_information": [
        {
          "code": "3007601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP,MULTI-PIN LG 390.004",
      "code_information": [
        {
          "code": "3008494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4727,
          "minimum": 992.67,
          "maximum": 3461.1094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3184.2206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-NV DSC & IN-LINE ACTIVATO",
      "code_information": [
        {
          "code": "3008690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LAPRA-TY ABS SUTURE XC200",
      "code_information": [
        {
          "code": "3008699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 777,
          "minimum": 163.17,
          "maximum": 568.9194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 523.4058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIPS-HEM-O-LOC         544230",
      "code_information": [
        {
          "code": "3008728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.3207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK LG       544240",
      "code_information": [
        {
          "code": "3008730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK XL       544250",
      "code_information": [
        {
          "code": "3008731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X3/8 XA6062",
      "code_information": [
        {
          "code": "3009659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 871,
          "minimum": 182.91,
          "maximum": 637.7462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 586.7265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR ACCU-FLO 82-1504",
      "code_information": [
        {
          "code": "3009774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 763.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONSTAVAC-CBC II    225-28-614",
      "code_information": [
        {
          "code": "3009792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1463,
          "minimum": 307.23,
          "maximum": 1071.2086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 985.5119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR BOVIE DISP 301538",
      "code_information": [
        {
          "code": "3009842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR HIGH   26176LD/10",
      "code_information": [
        {
          "code": "3009843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.6147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNULATED",
      "code_information": [
        {
          "code": "3009845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1933,
          "minimum": 405.93,
          "maximum": 1415.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1302.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNUL 3.8MM",
      "code_information": [
        {
          "code": "3009850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1211.8496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-SILICONE RETRACTOR",
      "code_information": [
        {
          "code": "3009851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.6262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-DISPOSABLE ACTIVE DAC",
      "code_information": [
        {
          "code": "3009853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 191.9828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-8 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 173.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 191.9828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 234.4212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-30 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 250.5881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 428,
          "minimum": 89.88,
          "maximum": 313.3816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 288.3111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 315.9297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CORONARY PERF    30055",
      "code_information": [
        {
          "code": "3010039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MERCEDES     PAL-506LL",
      "code_information": [
        {
          "code": "3010053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS ALL SZS   681xx",
      "code_information": [
        {
          "code": "3010076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 551,
          "minimum": 115.71,
          "maximum": 403.4422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 371.1668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT ALL SZ",
      "code_information": [
        {
          "code": "3010079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL 1X4  2111-04-077",
      "code_information": [
        {
          "code": "3010088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2712,
          "minimum": 569.52,
          "maximum": 1985.7264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1826.8683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL ALL  2111-08-07x",
      "code_information": [
        {
          "code": "3010090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5695,
          "minimum": 1195.95,
          "maximum": 4169.879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3836.2887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X20 657320",
      "code_information": [
        {
          "code": "3010104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.4759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X40 657340",
      "code_information": [
        {
          "code": "3010107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.4759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DUBIN              8390",
      "code_information": [
        {
          "code": "3010215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION         BID30",
      "code_information": [
        {
          "code": "3010259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 890,
          "minimum": 186.9,
          "maximum": 651.658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 599.5254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE LITE 30-403LITE",
      "code_information": [
        {
          "code": "3010311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3419,
          "minimum": 717.99,
          "maximum": 2503.3918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2303.1205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LAPARSCOP PLUME FILTER",
      "code_information": [
        {
          "code": "3010330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 133.3776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VAGINAL POSITIONING",
      "code_information": [
        {
          "code": "3010598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2367,
          "minimum": 497.07,
          "maximum": 1733.1174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1594.468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-BLUNT TIP 5 PK BTD05",
      "code_information": [
        {
          "code": "3010867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1 5901-1126",
      "code_information": [
        {
          "code": "3011002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHAN W/TROCAR ALL SIZES",
      "code_information": [
        {
          "code": "3011730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 199,
          "minimum": 41.79,
          "maximum": 145.7078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT HUBLESS ALL SZS",
      "code_information": [
        {
          "code": "3011780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-MINI CHEST 500     16400",
      "code_information": [
        {
          "code": "3011787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1139,
          "minimum": 239.19,
          "maximum": 833.9758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.2577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FECAL MANAGEMENT 418000",
      "code_information": [
        {
          "code": "3011910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1469,
          "minimum": 308.49,
          "maximum": 1075.6018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 989.5537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FECAL MANAGEMENT 411108",
      "code_information": [
        {
          "code": "3011911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-HIP W/POUCHES DYNJP8201",
      "code_information": [
        {
          "code": "3011920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.1764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BEACH CHAIR SHOULDER",
      "code_information": [
        {
          "code": "3011922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 257,
          "minimum": 53.97,
          "maximum": 188.1754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 173.1214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BARIATRIC      DYNJP3105",
      "code_information": [
        {
          "code": "3011926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 153.5863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-DOUBLE 44X66     ORS 320",
      "code_information": [
        {
          "code": "3011927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 328.7285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 12MM CD004",
      "code_information": [
        {
          "code": "3011949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE 3M SHORT   6661EZ",
      "code_information": [
        {
          "code": "3011953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-ISO IOBAN HIP       6617",
      "code_information": [
        {
          "code": "3011959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.8576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INTESTINAL 18X18.5 ISO1003",
      "code_information": [
        {
          "code": "3011960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 360,
          "minimum": 75.6,
          "maximum": 263.592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.5046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 10MM CD001",
      "code_information": [
        {
          "code": "3011961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI     326088-0000-000",
      "code_information": [
        {
          "code": "3011985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.8899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI FULL         306070",
      "code_information": [
        {
          "code": "3011987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 279,
          "minimum": 58.59,
          "maximum": 204.2838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 187.9411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER           ORS-400",
      "code_information": [
        {
          "code": "3011995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.1118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERI IRRIGATION    1016",
      "code_information": [
        {
          "code": "3012018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE HAND   DYNJP8005",
      "code_information": [
        {
          "code": "3012025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR GLASSCOCK  S-1000",
      "code_information": [
        {
          "code": "3012051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GENTLE CARE SURG 12-1",
      "code_information": [
        {
          "code": "3012060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 480,
          "minimum": 100.8,
          "maximum": 351.456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 323.3395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-TOPIFOAM      5710-30",
      "code_information": [
        {
          "code": "3012080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.4136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN TWIST 2.7MM W/AO F",
      "code_information": [
        {
          "code": "3012109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2077,
          "minimum": 436.17,
          "maximum": 1520.7794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1399.117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.0MM ASNIS",
      "code_information": [
        {
          "code": "3012113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1913,
          "minimum": 401.73,
          "maximum": 1400.6986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1288.6427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-HEX 1.1X67       15-1723",
      "code_information": [
        {
          "code": "3012115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1211,
          "minimum": 254.31,
          "maximum": 886.6942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 815.7587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3012118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN 4.0MM W/AO",
      "code_information": [
        {
          "code": "3012152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5392,
          "minimum": 1132.32,
          "maximum": 3948.0224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3632.1806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SHAFT-AO 2.6MMX122MM",
      "code_information": [
        {
          "code": "3012186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 984.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           310.48",
      "code_information": [
        {
          "code": "3012201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1176,
          "minimum": 246.96,
          "maximum": 861.0672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 792.1818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO SMALL  1320-3042S",
      "code_information": [
        {
          "code": "3012204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1181,
          "minimum": 248.01,
          "maximum": 864.7282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 795.5499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1806-5010S",
      "code_information": [
        {
          "code": "3012206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1103,
          "minimum": 231.63,
          "maximum": 807.6166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 743.0073,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 03.6MMX122MM",
      "code_information": [
        {
          "code": "3012207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1378,
          "minimum": 289.38,
          "maximum": 1008.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 928.2539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM       60-19326",
      "code_information": [
        {
          "code": "3012208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 749.0699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 13.0MM CANNULATED",
      "code_information": [
        {
          "code": "3012314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4464,
          "minimum": 937.44,
          "maximum": 3268.5408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3007.0575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0           310.21",
      "code_information": [
        {
          "code": "3012318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.7625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         MS-DCR20",
      "code_information": [
        {
          "code": "3012321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 LG 120MM",
      "code_information": [
        {
          "code": "3012325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1725,
          "minimum": 362.25,
          "maximum": 1263.045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1162.0014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 315.28",
      "code_information": [
        {
          "code": "3012330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1374,
          "minimum": 288.54,
          "maximum": 1006.0428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 925.5594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          310.288",
      "code_information": [
        {
          "code": "3012331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2           405883",
      "code_information": [
        {
          "code": "3012341",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1098,
          "minimum": 230.58,
          "maximum": 803.9556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 739.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X40   2274-12-000",
      "code_information": [
        {
          "code": "3012344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1940,
          "minimum": 407.4,
          "maximum": 1420.468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1306.8306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5          MS-DC35",
      "code_information": [
        {
          "code": "3012346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1055,
          "minimum": 221.55,
          "maximum": 772.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 710.6733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.201",
      "code_information": [
        {
          "code": "3012355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 912,
          "minimum": 191.52,
          "maximum": 667.7664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 614.3451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL               310.28",
      "code_information": [
        {
          "code": "3012356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.7625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.431",
      "code_information": [
        {
          "code": "3012357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1411,
          "minimum": 296.31,
          "maximum": 1033.1342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 950.4835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL            32-486265",
      "code_information": [
        {
          "code": "3012365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 769,
          "minimum": 161.49,
          "maximum": 563.0618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 518.0169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL         5820-107-530",
      "code_information": [
        {
          "code": "3012374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           AT2M-L1813",
      "code_information": [
        {
          "code": "3012378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2410,
          "minimum": 506.1,
          "maximum": 1764.602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1623.4338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED   310.634",
      "code_information": [
        {
          "code": "3012380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1800.597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 5.0MM",
      "code_information": [
        {
          "code": "3012381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1800.597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM 60-19340",
      "code_information": [
        {
          "code": "3012401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 742.3336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHRT 3.2 03.010.103S",
      "code_information": [
        {
          "code": "3012406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1666,
          "minimum": 349.86,
          "maximum": 1219.8452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1122.2576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL 5MM     DBL-511",
      "code_information": [
        {
          "code": "3012461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL LOOP      B0512",
      "code_information": [
        {
          "code": "3012465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 250.5881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X2.75 E1455",
      "code_information": [
        {
          "code": "3012472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X4  E1455-4",
      "code_information": [
        {
          "code": "3012473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-208",
      "code_information": [
        {
          "code": "3012474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1372,
          "minimum": 288.12,
          "maximum": 1004.5784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 924.2121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EZ CLEAN CAUTERY TIP",
      "code_information": [
        {
          "code": "3012505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.3757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE MOD     0014AM",
      "code_information": [
        {
          "code": "3012507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK  E2773-45",
      "code_information": [
        {
          "code": "3012520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 280.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MRI CONDITIONAL DISP",
      "code_information": [
        {
          "code": "3012521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LIGASURE      LS1037",
      "code_information": [
        {
          "code": "3012535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2512,
          "minimum": 527.52,
          "maximum": 1839.2864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1692.1435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 2CHAN 8227410",
      "code_information": [
        {
          "code": "3012585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1545,
          "minimum": 324.45,
          "maximum": 1131.249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1040.7491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDISPEC        SE-1",
      "code_information": [
        {
          "code": "3012590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 369.8196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-RADIUS LOOP    R1010",
      "code_information": [
        {
          "code": "3012596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 250.5881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 6.5\\\" 0014M",
      "code_information": [
        {
          "code": "3012611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-TEFLON 6 1/2 BLADE",
      "code_information": [
        {
          "code": "3012613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDCAP-ROUND X-CORE    5960200",
      "code_information": [
        {
          "code": "3012635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4702,
          "minimum": 987.42,
          "maximum": 3442.8044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3167.38,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3012680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2877,
          "minimum": 604.17,
          "maximum": 2106.5394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1938.0162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVACUATOR-UROVAC       730-125",
      "code_information": [
        {
          "code": "3012699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVAC-SAF-T-VAC         ST9000S",
      "code_information": [
        {
          "code": "3012723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.2523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-GLUE             540133500",
      "code_information": [
        {
          "code": "3012805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXCISOR-BIOPSY CONE",
      "code_information": [
        {
          "code": "3012815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-DIALYSIS CATH  415612",
      "code_information": [
        {
          "code": "3012854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1265,
          "minimum": 265.65,
          "maximum": 926.233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 852.1344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTRACTOR-TRIGEN DISP 71631320",
      "code_information": [
        {
          "code": "3012895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.7529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBE-VIPERSLIDE VPR-SLD2",
      "code_information": [
        {
          "code": "3012925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 1X6        007976",
      "code_information": [
        {
          "code": "3012991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.0889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 4\\\"X4\\\"       007836",
      "code_information": [
        {
          "code": "3012993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2074,
          "minimum": 435.54,
          "maximum": 1518.5828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1397.0962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 200M",
      "code_information": [
        {
          "code": "3013060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2420,
          "minimum": 508.2,
          "maximum": 1771.924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1630.1701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 365M",
      "code_information": [
        {
          "code": "3013061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2010,
          "minimum": 422.1,
          "maximum": 1471.722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1353.9842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 550M",
      "code_information": [
        {
          "code": "3013062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2649,
          "minimum": 556.29,
          "maximum": 1939.5978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1784.43,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 1000M",
      "code_information": [
        {
          "code": "3013063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3743,
          "minimum": 786.03,
          "maximum": 2740.6246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2521.3746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-COUDE HEYMAN   021300",
      "code_information": [
        {
          "code": "3013087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1917,
          "minimum": 402.57,
          "maximum": 1403.6274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1291.3372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-HEYMAN         021100",
      "code_information": [
        {
          "code": "3013090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1718,
          "minimum": 360.78,
          "maximum": 1257.9196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1157.286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPER-          AR-7237-7",
      "code_information": [
        {
          "code": "3013107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 3  AR-7227-01",
      "code_information": [
        {
          "code": "3013134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 221.6223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 4  AR-7230-01",
      "code_information": [
        {
          "code": "3013135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-HEPA BACTERIA 00182",
      "code_information": [
        {
          "code": "3013160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PED OXYKID W/7' TUBING",
      "code_information": [
        {
          "code": "3013161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-INSUFFLATION BULB",
      "code_information": [
        {
          "code": "3013164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.6129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP     1599-05",
      "code_information": [
        {
          "code": "3013203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 237,
          "minimum": 49.77,
          "maximum": 173.5314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.6489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-PIRANHA 3FR     505-160",
      "code_information": [
        {
          "code": "3013317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2055,
          "minimum": 431.55,
          "maximum": 1504.671,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1384.2973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW      000300s",
      "code_information": [
        {
          "code": "3013320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RJ4 LC BIOPSY 160CM",
      "code_information": [
        {
          "code": "3013323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.6129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GEL-PROLARYN          8602M0K5",
      "code_information": [
        {
          "code": "3013462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4034,
          "minimum": 847.14,
          "maximum": 2953.6948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2717.3992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3014234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 675.6449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 6.5 DRILL",
      "code_information": [
        {
          "code": "3014235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.0793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-AR-8737-01",
      "code_information": [
        {
          "code": "3014239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3014272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.7381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-DBX MIX 2.5CC     058025",
      "code_information": [
        {
          "code": "3014900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2432,
          "minimum": 510.72,
          "maximum": 1780.7104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1638.2536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-WIRE .035      WS-0906ST",
      "code_information": [
        {
          "code": "3016121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.6831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2MM           292.65",
      "code_information": [
        {
          "code": "3016129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 552,
          "minimum": 115.92,
          "maximum": 404.1744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 371.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0MM 702460",
      "code_information": [
        {
          "code": "3016131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K SMOOTH TIP AGK16100",
      "code_information": [
        {
          "code": "3016134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-3.2       03.010.115",
      "code_information": [
        {
          "code": "3016135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1091,
          "minimum": 229.11,
          "maximum": 798.8302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 734.9238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K W/OLIVE STOP",
      "code_information": [
        {
          "code": "3016136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 949.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-SUT GABBY-FRATER SUT 013",
      "code_information": [
        {
          "code": "3016153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.6147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDETHREAD 150MM  292.72",
      "code_information": [
        {
          "code": "3016158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 461,
          "minimum": 96.81,
          "maximum": 337.5442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 310.5407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP AR894301",
      "code_information": [
        {
          "code": "3016164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.4136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-HALTER DISP 08143101",
      "code_information": [
        {
          "code": "3016272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 118,
          "minimum": 24.78,
          "maximum": 86.3996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 79.4876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ADHESIVE 4\\\" WHITE",
      "code_information": [
        {
          "code": "3016326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1963",
      "code_information": [
        {
          "code": "3016347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1292,
          "minimum": 271.32,
          "maximum": 946.0024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 870.3222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOVAC-400ML LG   2550-004-10",
      "code_information": [
        {
          "code": "3016381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-HYDRODEB     1914001",
      "code_information": [
        {
          "code": "3016387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2186,
          "minimum": 459.06,
          "maximum": 1600.5892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1472.5421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM SNGL PK 33508G",
      "code_information": [
        {
          "code": "3016420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.6831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM DOUBLE  3384-4",
      "code_information": [
        {
          "code": "3016425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 434,
          "minimum": 91.14,
          "maximum": 317.7748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 292.3528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 2X4 2082",
      "code_information": [
        {
          "code": "3016450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.0889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 4X4 2083",
      "code_information": [
        {
          "code": "3016451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1255,
          "minimum": 263.55,
          "maximum": 918.911,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 845.3981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-J CAUTERY     60-5272-232",
      "code_information": [
        {
          "code": "3016500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-ULTRASLING III XLG",
      "code_information": [
        {
          "code": "3017486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 291.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUTTLE-ACCU PASS SUTURE 70DEG",
      "code_information": [
        {
          "code": "3019705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1334,
          "minimum": 280.14,
          "maximum": 976.7548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 898.6144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-EVERGRIP LF  EVERGRIP61",
      "code_information": [
        {
          "code": "3019748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.9069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FDG",
      "code_information": [
        {
          "code": "3019810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2674,
          "minimum": 561.54,
          "maximum": 1957.9028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1801.2706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGL",
      "code_information": [
        {
          "code": "3019813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2674,
          "minimum": 561.54,
          "maximum": 1957.9028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1801.2706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGD",
      "code_information": [
        {
          "code": "3019815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3010,
          "minimum": 632.1,
          "maximum": 2203.922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2027.6082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-PEELAWAY 16F",
      "code_information": [
        {
          "code": "3019878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 615,
          "minimum": 129.15,
          "maximum": 450.303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 414.2788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT 9FR 3 1/2 PI93",
      "code_information": [
        {
          "code": "3019879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 381,
          "minimum": 80.01,
          "maximum": 278.9682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 256.6507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP NICU HNICU37",
      "code_information": [
        {
          "code": "3019903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2MM 500373",
      "code_information": [
        {
          "code": "3020202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 709,
          "minimum": 148.89,
          "maximum": 519.1298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 477.5994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPER DISTRACTOR FF904SB",
      "code_information": [
        {
          "code": "3020203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1060,
          "minimum": 222.6,
          "maximum": 776.132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 714.0414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 17L 96550",
      "code_information": [
        {
          "code": "3020800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 515,
          "minimum": 108.15,
          "maximum": 377.083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 346.9164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-I RING PUPIL 587000",
      "code_information": [
        {
          "code": "3020804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1251,
          "minimum": 262.71,
          "maximum": 915.9822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 842.7036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL VISULIZATION",
      "code_information": [
        {
          "code": "3020806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUG 03.804.522S",
      "code_information": [
        {
          "code": "3020807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 859,
          "minimum": 180.39,
          "maximum": 628.9598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 578.643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SCOPE WARMER TM500",
      "code_information": [
        {
          "code": "3020808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENTI SCAN IV DISP 177-092",
      "code_information": [
        {
          "code": "3020810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 451,
          "minimum": 94.71,
          "maximum": 330.2222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.8044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESSORY 700     72401850",
      "code_information": [
        {
          "code": "3020811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5472,
          "minimum": 1149.12,
          "maximum": 4006.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3686.0705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COAG  CSP208",
      "code_information": [
        {
          "code": "3020850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DILATOR NVM5       2029950",
      "code_information": [
        {
          "code": "3020915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3230.0271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-19",
      "code_information": [
        {
          "code": "3020920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.4759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-21",
      "code_information": [
        {
          "code": "3020922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2245,
          "minimum": 471.45,
          "maximum": 1643.789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1512.2859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC     96530-017",
      "code_information": [
        {
          "code": "3020928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 792.8554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IV MAXCESS         3240060",
      "code_information": [
        {
          "code": "3020969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8227,
          "minimum": 1727.67,
          "maximum": 6023.8094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5541.9046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX PT STARTER  50-0071",
      "code_information": [
        {
          "code": "3021029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.9253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHUNT NONINVASIVE  9733605",
      "code_information": [
        {
          "code": "3021032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3599,
          "minimum": 755.79,
          "maximum": 2635.1878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2424.3728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 4ML 1501262",
      "code_information": [
        {
          "code": "3021034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1084.5346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH&BOOT 3550-80",
      "code_information": [
        {
          "code": "3021046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 476,
          "minimum": 99.96,
          "maximum": 348.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 320.645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERITONEAL DIALYSIS 278006",
      "code_information": [
        {
          "code": "3021065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 774.6676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHOULDER CANNULA 5CM  9718",
      "code_information": [
        {
          "code": "3021080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-URO MAX HI PRESURE 225-136",
      "code_information": [
        {
          "code": "3021090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1753,
          "minimum": 368.13,
          "maximum": 1283.5466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1180.8629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXTRACTION GTG14",
      "code_information": [
        {
          "code": "3021113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4570,
          "minimum": 959.7,
          "maximum": 3346.154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3078.4617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X12MM 663812",
      "code_information": [
        {
          "code": "3021130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 951,
          "minimum": 199.71,
          "maximum": 696.3222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 640.6164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CRESCENT         74-1010",
      "code_information": [
        {
          "code": "3021150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 81.5085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE,SLIT 2.4MM 45 DEGREE",
      "code_information": [
        {
          "code": "3021161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 177.1631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-GRAFT ACL 10MM    232110",
      "code_information": [
        {
          "code": "3021173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2004,
          "minimum": 420.84,
          "maximum": 1467.3288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1349.9425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT CLEAR CUT 2.4",
      "code_information": [
        {
          "code": "3021199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 328.7285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDE PORT 1.1    78-2010",
      "code_information": [
        {
          "code": "3021203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-TUIP             880-217",
      "code_information": [
        {
          "code": "3021220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 749,
          "minimum": 157.29,
          "maximum": 548.4178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 504.5444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE ALL AR-4000Ss",
      "code_information": [
        {
          "code": "3021225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE         AR-4068's",
      "code_information": [
        {
          "code": "3021227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 984.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDEPORT SAFETY 1.0MM",
      "code_information": [
        {
          "code": "3021241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.2542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINER-SZ25/36MM RL 12-105995",
      "code_information": [
        {
          "code": "3021635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4400,
          "minimum": 924,
          "maximum": 3221.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2963.9456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-IMPACT         LF4318",
      "code_information": [
        {
          "code": "3021733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2708,
          "minimum": 568.68,
          "maximum": 1982.7976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1824.1738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-DRAINAGE LOCKABLE 50-7245",
      "code_information": [
        {
          "code": "3021737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 175.8159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 26FR      880-214",
      "code_information": [
        {
          "code": "3021821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 467.4951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-DISPOSA ALL",
      "code_information": [
        {
          "code": "3021826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-ELECTRODE 24FR   WA22037C",
      "code_information": [
        {
          "code": "3021880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1483,
          "minimum": 311.43,
          "maximum": 1085.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 998.9844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WIRE SNARE 8-14515",
      "code_information": [
        {
          "code": "3021881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 395.4173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-MS SSEP NEEDLE  8050315",
      "code_information": [
        {
          "code": "3022945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5246,
          "minimum": 1101.66,
          "maximum": 3841.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3533.8315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE MEP/EMG",
      "code_information": [
        {
          "code": "3022955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3419.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SINGLE PORT PAL 240LS",
      "code_information": [
        {
          "code": "3023177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 536.2047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY STEALTH  9733068",
      "code_information": [
        {
          "code": "3027284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4784,
          "minimum": 1004.64,
          "maximum": 3502.8448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3222.6172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY TRU CUT 2N2700s",
      "code_information": [
        {
          "code": "3027285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.8083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY CUT      4418-16",
      "code_information": [
        {
          "code": "3027295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DEFLUX 23GX3.7FX350mm",
      "code_information": [
        {
          "code": "3027296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 744,
          "minimum": 156.24,
          "maximum": 544.7568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 501.1763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DISP INSUF      S100000",
      "code_information": [
        {
          "code": "3027310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 482,
          "minimum": 101.22,
          "maximum": 352.9204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 324.6868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ELECTRODE COATD E1465-6",
      "code_information": [
        {
          "code": "3027313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ENDOPATH INSUFF   PN120",
      "code_information": [
        {
          "code": "3027315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 719,
          "minimum": 150.99,
          "maximum": 526.4518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 484.3357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL       105-1314",
      "code_information": [
        {
          "code": "3027318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-20      G00013",
      "code_information": [
        {
          "code": "3027330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FORAMEN 20G      041829",
      "code_information": [
        {
          "code": "3027344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-6 DJ6011X",
      "code_information": [
        {
          "code": "3027346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 292,
          "minimum": 61.32,
          "maximum": 213.8024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 196.6982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR        1650050",
      "code_information": [
        {
          "code": "3027347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 390,
          "minimum": 81.9,
          "maximum": 285.558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.7134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSULATED EDGE   E1465B",
      "code_information": [
        {
          "code": "3027368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TR-CRON 2-0 STR W/10 SW",
      "code_information": [
        {
          "code": "3027402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 294.3737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR W/SHEATH",
      "code_information": [
        {
          "code": "3027403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 626,
          "minimum": 131.46,
          "maximum": 458.3572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 421.6886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OPUS SPEEDSTITCH",
      "code_information": [
        {
          "code": "3027425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 397,
          "minimum": 83.37,
          "maximum": 290.6834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 267.4287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OCTRODE 6\\\"         1116",
      "code_information": [
        {
          "code": "3027430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODESSECTION   N103A",
      "code_information": [
        {
          "code": "3027433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 690,
          "minimum": 144.9,
          "maximum": 505.218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 464.8006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION      AR-13991N",
      "code_information": [
        {
          "code": "3027443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 984.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SIDEKICK 21GA 14.6\\\"",
      "code_information": [
        {
          "code": "3027445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 793,
          "minimum": 166.53,
          "maximum": 580.6346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 534.1838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODISSECTION   E1xxx",
      "code_information": [
        {
          "code": "3027520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 795,
          "minimum": 166.95,
          "maximum": 582.099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 535.5311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-W/BASEPLATE BSDN-18-7.0",
      "code_information": [
        {
          "code": "3027587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 5MM  VS101005",
      "code_information": [
        {
          "code": "3027591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1299,
          "minimum": 272.79,
          "maximum": 951.1278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 875.0376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VERSASTEP 14GA VS150000",
      "code_information": [
        {
          "code": "3027593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 600,
          "minimum": 126,
          "maximum": 439.32,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 404.1744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TROCAR 12MM VS101000s",
      "code_information": [
        {
          "code": "3027595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1224,
          "minimum": 257.04,
          "maximum": 896.2128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 824.5158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-WILSON PENILE IMPLANT",
      "code_information": [
        {
          "code": "3029175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2504,
          "minimum": 525.84,
          "maximum": 1833.4288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1686.7545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FENWAL TRANSFER 4R2014",
      "code_information": [
        {
          "code": "3029199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-EXTREMITY      DYNJ31779F",
      "code_information": [
        {
          "code": "3029200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 671,
          "minimum": 140.91,
          "maximum": 491.3062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 452.0017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAGNETIC DRAPE    31140562",
      "code_information": [
        {
          "code": "3029201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.6129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY ELITE VIAL     LC3001",
      "code_information": [
        {
          "code": "3029202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3536,
          "minimum": 742.56,
          "maximum": 2589.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2381.9345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SENSA TRAC M8275057/10",
      "code_information": [
        {
          "code": "3029214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-PERFUSION CUSTOM  CK0226R",
      "code_information": [
        {
          "code": "3029252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3994,
          "minimum": 838.74,
          "maximum": 2924.4068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2690.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SHOULDER ARTHROSCOP 29367",
      "code_information": [
        {
          "code": "3029266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 175.8159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SINUS KENNEDY      400422",
      "code_information": [
        {
          "code": "3029267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-TOTAL JOINT    DYNJ31778A",
      "code_information": [
        {
          "code": "3029268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 794.8763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM     440400",
      "code_information": [
        {
          "code": "3029278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HAND DYNJ52365",
      "code_information": [
        {
          "code": "3029301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 636,
          "minimum": 133.56,
          "maximum": 465.6792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 428.4249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VITRECTOMY CENTURION",
      "code_information": [
        {
          "code": "3029308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH  82-151x",
      "code_information": [
        {
          "code": "3029345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1307,
          "minimum": 274.47,
          "maximum": 956.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 880.4266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SMART STITCH PERFECT",
      "code_information": [
        {
          "code": "3029347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 917,
          "minimum": 192.57,
          "maximum": 671.4274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 617.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE           032401",
      "code_information": [
        {
          "code": "3029348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE LF 022701",
      "code_information": [
        {
          "code": "3029356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 713,
          "minimum": 149.73,
          "maximum": 522.0586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 480.2939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-HEMA KNITTED   HGK75/75P",
      "code_information": [
        {
          "code": "3029426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1254,
          "minimum": 263.34,
          "maximum": 918.1788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 844.7245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-ACTIVA 2.5 INTELLIDOSE",
      "code_information": [
        {
          "code": "3029528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-DISPOSABLE  26-1221",
      "code_information": [
        {
          "code": "3029529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1803.9651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORIENTATION 2307-71-000",
      "code_information": [
        {
          "code": "3029762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.5823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-NAVIGATION 6007-003-150",
      "code_information": [
        {
          "code": "3029767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 629.8384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ARM ELEVATION 79-90500",
      "code_information": [
        {
          "code": "3029771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KNEE PROCEDURE TRACK 10712",
      "code_information": [
        {
          "code": "3029811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.4759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-DEMAYO LEG 110550",
      "code_information": [
        {
          "code": "3029813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BREAKAWAY GUIDE 2.5MM",
      "code_information": [
        {
          "code": "3029840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2605,
          "minimum": 547.05,
          "maximum": 1907.381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1754.7905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144110",
      "code_information": [
        {
          "code": "3029841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1086,
          "minimum": 228.06,
          "maximum": 795.1692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 731.5557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DHS GUIDE          900.723",
      "code_information": [
        {
          "code": "3029855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 658,
          "minimum": 138.18,
          "maximum": 481.7876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 443.2446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-POSITIONING EZ CLIP 2MM",
      "code_information": [
        {
          "code": "3029858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 756.4798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-FLUTED HEADLESS 7650-2038A",
      "code_information": [
        {
          "code": "3029885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1881,
          "minimum": 395.01,
          "maximum": 1377.2682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1267.0867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE              357.399",
      "code_information": [
        {
          "code": "3029929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1109,
          "minimum": 232.89,
          "maximum": 812.0098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 747.049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PINS-GUIDE 7.3         900.726",
      "code_information": [
        {
          "code": "3030050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 943,
          "minimum": 198.03,
          "maximum": 690.4646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 635.2274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z463G",
      "code_information": [
        {
          "code": "3032618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1\\\"",
      "code_information": [
        {
          "code": "3033301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 48,
          "minimum": 10.08,
          "maximum": 35.1456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 32.334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 16FR 10ML",
      "code_information": [
        {
          "code": "3033303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F SCREWS 45-80040",
      "code_information": [
        {
          "code": "3033883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 984.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-LARGE SOFT       PCP40",
      "code_information": [
        {
          "code": "3033952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POINTER-TRACER         9733423",
      "code_information": [
        {
          "code": "3034140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3396,
          "minimum": 713.16,
          "maximum": 2486.5512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2287.6271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-BIOPSY             AUR-BP",
      "code_information": [
        {
          "code": "3034190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 316,
          "minimum": 66.36,
          "maximum": 231.3752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.8652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-GEL HAND            C8XX2",
      "code_information": [
        {
          "code": "3034194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2660.1412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOCATCH-II W/POUCH ALL 173's",
      "code_information": [
        {
          "code": "3034302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2140,
          "minimum": 449.4,
          "maximum": 1566.908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1441.5554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD ENTERAL 7FR 350CM",
      "code_information": [
        {
          "code": "3034510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NEUROVISION M5   2012021",
      "code_information": [
        {
          "code": "3034522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PIGTAIL 28-0174",
      "code_information": [
        {
          "code": "3034526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 717.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LAPAROSCOPIC 5MM  160655",
      "code_information": [
        {
          "code": "3034572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 775.3412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 2.3MM 6.9FR 300CM",
      "code_information": [
        {
          "code": "3034891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-WOUND GELPOINT CNGL2",
      "code_information": [
        {
          "code": "3038330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2850.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-PAIN ONQ 400ML    PM028-A",
      "code_information": [
        {
          "code": "3038635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1884,
          "minimum": 395.64,
          "maximum": 1379.4648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1269.1076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-KNOT 2-0 FIBERWIRE",
      "code_information": [
        {
          "code": "3038667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.0793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-DEKNATEL 4.4      MDP-44",
      "code_information": [
        {
          "code": "3038930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 398,
          "minimum": 83.58,
          "maximum": 291.4156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 268.1024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GREEN    ECR45G",
      "code_information": [
        {
          "code": "3039881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1406,
          "minimum": 295.26,
          "maximum": 1029.4732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 947.1153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO LINEAR       TR35B",
      "code_information": [
        {
          "code": "3039888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 838,
          "minimum": 175.98,
          "maximum": 613.5836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 564.4969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-TUBING         RF10210",
      "code_information": [
        {
          "code": "3039889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W564",
      "code_information": [
        {
          "code": "3039894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W332",
      "code_information": [
        {
          "code": "3039896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN        XR30G",
      "code_information": [
        {
          "code": "3039899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 290.3319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH       170056",
      "code_information": [
        {
          "code": "3039902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 580.6639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-VASCULAR/THIN     TR45W",
      "code_information": [
        {
          "code": "3039909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 819.1268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM              XR30B",
      "code_information": [
        {
          "code": "3039911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 290.3319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STANDARD BLUE     6R45B",
      "code_information": [
        {
          "code": "3039912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 819.1268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40B",
      "code_information": [
        {
          "code": "3039913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1699,
          "minimum": 356.79,
          "maximum": 1244.0078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1144.4872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD- STAPLE TCR-55",
      "code_information": [
        {
          "code": "3039914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 499,
          "minimum": 104.79,
          "maximum": 365.3678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 336.1384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-LINEAR CUTTER    TCR-75",
      "code_information": [
        {
          "code": "3039916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 820,
          "minimum": 172.2,
          "maximum": 600.404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 552.3717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40G",
      "code_information": [
        {
          "code": "3039917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1699,
          "minimum": 356.79,
          "maximum": 1244.0078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1144.4872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER    TCT75",
      "code_information": [
        {
          "code": "3039918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1465,
          "minimum": 307.65,
          "maximum": 1072.673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 986.8592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM BLUE         XR60B",
      "code_information": [
        {
          "code": "3039920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 514,
          "minimum": 107.94,
          "maximum": 376.3508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 346.2427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO GIA 30/3.5  030452",
      "code_information": [
        {
          "code": "3039932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2061,
          "minimum": 432.81,
          "maximum": 1509.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.3391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-CARIOTOMY        205",
      "code_information": [
        {
          "code": "3039975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 465,
          "minimum": 97.65,
          "maximum": 340.473,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.2352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-DISP FILTRA 04259",
      "code_information": [
        {
          "code": "3039981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 394.07,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-OMMAYA    NL850-121x",
      "code_information": [
        {
          "code": "3040439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3043,
          "minimum": 639.03,
          "maximum": 2228.0846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2049.8378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD UNIV     050602",
      "code_information": [
        {
          "code": "3040461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 206.1289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-C-SECTION DISP G6314",
      "code_information": [
        {
          "code": "3040500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 555.0662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND          C8404",
      "code_information": [
        {
          "code": "3040501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 555.0662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEXOR TENDON",
      "code_information": [
        {
          "code": "3040509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1803.9651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-LONESTAR        3304",
      "code_information": [
        {
          "code": "3040511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1080,
          "minimum": 226.8,
          "maximum": 790.776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 727.5139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ORTHO ALEXIS   HR004",
      "code_information": [
        {
          "code": "3040513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1611,
          "minimum": 338.31,
          "maximum": 1179.5742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1085.2083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE        013593",
      "code_information": [
        {
          "code": "3040518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 558,
          "minimum": 117.18,
          "maximum": 408.5676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 375.8822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-SURGICAL RING   3715",
      "code_information": [
        {
          "code": "3040521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1370,
          "minimum": 287.7,
          "maximum": 1003.114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 922.8649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-LOOPED 3 PRONG  5030",
      "code_information": [
        {
          "code": "3040525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 503.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND LG       C8303",
      "code_information": [
        {
          "code": "3040527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND MEDIUM   C8302",
      "code_information": [
        {
          "code": "3040530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XL       C8304",
      "code_information": [
        {
          "code": "3040532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 555.0662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND SMALL    C8301",
      "code_information": [
        {
          "code": "3040533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XSMALL   C8312",
      "code_information": [
        {
          "code": "3040534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-MALYUGIN ALL SZS MAL-000x",
      "code_information": [
        {
          "code": "3040661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1565,
          "minimum": 328.65,
          "maximum": 1145.893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.2216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.8 CANN DRI",
      "code_information": [
        {
          "code": "3040704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.2443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-2.0X7          AR-7200S",
      "code_information": [
        {
          "code": "3044850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 2.3 BIPOLAR",
      "code_information": [
        {
          "code": "3044897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1876.0428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS MALLEABLE BI",
      "code_information": [
        {
          "code": "3044899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3215,
          "minimum": 675.15,
          "maximum": 2354.023,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2165.7012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION ANSPACH 111613",
      "code_information": [
        {
          "code": "3044922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 650.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCISSORS-ENDODUT METZ     3142",
      "code_information": [
        {
          "code": "3044930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 460,
          "minimum": 96.6,
          "maximum": 336.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 309.867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68HP ALL",
      "code_information": [
        {
          "code": "3049715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY ALL 351-3000'sS",
      "code_information": [
        {
          "code": "3049750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRI PORT III PAL 303LS",
      "code_information": [
        {
          "code": "3050004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 4.0X170 144170",
      "code_information": [
        {
          "code": "3050009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 636.5747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CELLEBRITY CYTOLOGY",
      "code_information": [
        {
          "code": "3050015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 234,
          "minimum": 49.14,
          "maximum": 171.3348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 157.628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATIR SM DISP 13MM",
      "code_information": [
        {
          "code": "3055843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.7039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 2ML 1506078",
      "code_information": [
        {
          "code": "3055845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1499,
          "minimum": 314.79,
          "maximum": 1097.5678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1009.7624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL ALL SZS 456.30Xs",
      "code_information": [
        {
          "code": "3055898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3677,
          "minimum": 772.17,
          "maximum": 2692.2994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2476.9154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MISTY NEB W/FILTER",
      "code_information": [
        {
          "code": "3058511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-HELIOCOIDAL RASP 3.2MM",
      "code_information": [
        {
          "code": "3058512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1092,
          "minimum": 229.32,
          "maximum": 799.5624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 735.5974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONE MILL DISP",
      "code_information": [
        {
          "code": "3058513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1791,
          "minimum": 376.11,
          "maximum": 1311.3702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1206.4606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-CORE IRRIGATION",
      "code_information": [
        {
          "code": "3058514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 472,
          "minimum": 99.12,
          "maximum": 345.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 317.9505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 2.3MM",
      "code_information": [
        {
          "code": "3058515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1089,
          "minimum": 228.69,
          "maximum": 797.3658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 733.5765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-SOFT TOUCH RND FLUTED ALL",
      "code_information": [
        {
          "code": "3058516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND ALL SIZES",
      "code_information": [
        {
          "code": "3058517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 860.2178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND COURSE ALL",
      "code_information": [
        {
          "code": "3058518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 3.0MM",
      "code_information": [
        {
          "code": "3058521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1089,
          "minimum": 228.69,
          "maximum": 797.3658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 733.5765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CUTTING DIAMOND 25.4X0.8",
      "code_information": [
        {
          "code": "3058522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 701.9162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 310.23S",
      "code_information": [
        {
          "code": "3058526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1551,
          "minimum": 325.71,
          "maximum": 1135.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1044.7908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 02.7 CSS-072-27",
      "code_information": [
        {
          "code": "3058530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1347,
          "minimum": 282.87,
          "maximum": 986.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 907.3715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110 143110",
      "code_information": [
        {
          "code": "3058543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 683,
          "minimum": 143.43,
          "maximum": 500.0926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 460.0852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EPIDURAL 117\\\" INF 1633902",
      "code_information": [
        {
          "code": "3058611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.4117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE 10X5",
      "code_information": [
        {
          "code": "3058612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1239,
          "minimum": 260.19,
          "maximum": 907.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 834.6201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-FLOW 50 COBLATION",
      "code_information": [
        {
          "code": "3058620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1833,
          "minimum": 384.93,
          "maximum": 1342.1226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1234.7528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ACCOMINIZER 4.0",
      "code_information": [
        {
          "code": "3058623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STONCUTTER 5.5 7205331",
      "code_information": [
        {
          "code": "3058624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 956,
          "minimum": 200.76,
          "maximum": 699.9832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 643.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3058625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 ORBIT 7205323",
      "code_information": [
        {
          "code": "3058626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 429.0985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4.0 1864G",
      "code_information": [
        {
          "code": "3058639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.8899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL FLEX MED 27MM",
      "code_information": [
        {
          "code": "3058643",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.7172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-RETRIEVAL 30MM DGN-538-5",
      "code_information": [
        {
          "code": "3058644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 941,
          "minimum": 197.61,
          "maximum": 689.0002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 633.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I KNIFE SURG 8065921552",
      "code_information": [
        {
          "code": "3058653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.3415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 2.0MM 5820-010-020",
      "code_information": [
        {
          "code": "3058655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1105,
          "minimum": 232.05,
          "maximum": 809.081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 744.3545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDO FEEDING 12FR X 60”",
      "code_information": [
        {
          "code": "3058693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 254.6299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MINI 4.0 283459",
      "code_information": [
        {
          "code": "3058696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1275,
          "minimum": 267.75,
          "maximum": 933.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 858.8706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 FULL RADIUS",
      "code_information": [
        {
          "code": "3058697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1275,
          "minimum": 267.75,
          "maximum": 933.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 858.8706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3058698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 919,
          "minimum": 192.99,
          "maximum": 672.8918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 619.0605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 018 14MMX34CM",
      "code_information": [
        {
          "code": "3058707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2850.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-240",
      "code_information": [
        {
          "code": "3058716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANOSCOPE-BEVELED DISP 103X18M",
      "code_information": [
        {
          "code": "3058720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-EXPEL NEPHR I/E 8.3/22",
      "code_information": [
        {
          "code": "3058729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1262,
          "minimum": 265.02,
          "maximum": 924.0364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 850.1135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH 15FR 71C",
      "code_information": [
        {
          "code": "3058737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-VPAD 2 INS-0050",
      "code_information": [
        {
          "code": "3058749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2207,
          "minimum": 463.47,
          "maximum": 1615.9654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1486.6882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-ALWAYS ON TIP INS-0352",
      "code_information": [
        {
          "code": "3058751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1965.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-19 GA ANSO INS-0382",
      "code_information": [
        {
          "code": "3058752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1965.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GA ANSO INS 0392",
      "code_information": [
        {
          "code": "3058753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1965.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GA NITINOL INS-5410",
      "code_information": [
        {
          "code": "3058754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4175,
          "minimum": 876.75,
          "maximum": 3056.935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2812.3802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPINPERC INS-5600",
      "code_information": [
        {
          "code": "3058755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2207,
          "minimum": 463.47,
          "maximum": 1615.9654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1486.6882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE DISTRACTOR DISP",
      "code_information": [
        {
          "code": "3058766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 379.9239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE 1.5X36",
      "code_information": [
        {
          "code": "3058775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 AR 8943-16",
      "code_information": [
        {
          "code": "3058786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1013,
          "minimum": 212.73,
          "maximum": 741.7186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 682.3811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPIN EWC BIOPSY GUIDE",
      "code_information": [
        {
          "code": "3058788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3127,
          "minimum": 656.67,
          "maximum": 2289.5894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2106.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DISP SHOULDER 1.8MM",
      "code_information": [
        {
          "code": "3058805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1659,
          "minimum": 348.39,
          "maximum": 1214.7198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1117.5422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENTRAINER-AIR RT008",
      "code_information": [
        {
          "code": "3058809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 5.0 5050",
      "code_information": [
        {
          "code": "3058819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58043,
          "minimum": 12189.03,
          "maximum": 42499.0846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39099.1578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 7.0 7050",
      "code_information": [
        {
          "code": "3058820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60044,
          "minimum": 12609.24,
          "maximum": 43964.2168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40447.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 BV-1 M8709",
      "code_information": [
        {
          "code": "3058836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 503.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 2MMXxxCM",
      "code_information": [
        {
          "code": "3058843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4220,
          "minimum": 886.2,
          "maximum": 3089.884,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2842.6933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX20CM",
      "code_information": [
        {
          "code": "3058844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5064,
          "minimum": 1063.44,
          "maximum": 3707.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3411.2319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX30CM",
      "code_information": [
        {
          "code": "3058845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5591,
          "minimum": 1174.11,
          "maximum": 4093.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.2318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 CX ALL",
      "code_information": [
        {
          "code": "3058846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2850.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HEATED AIRVO 900PT501",
      "code_information": [
        {
          "code": "3058860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO SM OPT942",
      "code_information": [
        {
          "code": "3058861",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 220.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO MED OPT944",
      "code_information": [
        {
          "code": "3058862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 220.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO LARGE OPT946",
      "code_information": [
        {
          "code": "3058863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 220.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-013-000 SZ4",
      "code_information": [
        {
          "code": "3058864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.4117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HEALING W/PLUG 30MM 95084",
      "code_information": [
        {
          "code": "3058868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 145.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN LITE FUD023",
      "code_information": [
        {
          "code": "3058869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.5MM",
      "code_information": [
        {
          "code": "3058875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CONTOUR CERVICAL 13-15",
      "code_information": [
        {
          "code": "3058876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.8899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-RIB UNIVERSAL 8” MALE",
      "code_information": [
        {
          "code": "3058877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3.0 1893G",
      "code_information": [
        {
          "code": "3058878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SLIM MED",
      "code_information": [
        {
          "code": "3058885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 156.9544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-SYSTEM UA2007",
      "code_information": [
        {
          "code": "3058887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 162,
          "minimum": 34.02,
          "maximum": 118.6164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.1271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WATER SUCTION BIOPSY VALVE",
      "code_information": [
        {
          "code": "3058903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.5711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-ACCUSTAT 125NM S 801015",
      "code_information": [
        {
          "code": "3058929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5081,
          "minimum": 1067.01,
          "maximum": 3720.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3422.6835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MIDLINE 5FR BIO FLO",
      "code_information": [
        {
          "code": "3058932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 1.4X27MM",
      "code_information": [
        {
          "code": "3058955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3358,
          "minimum": 705.18,
          "maximum": 2458.7276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2262.0294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON,CAPIOX HPH-1000",
      "code_information": [
        {
          "code": "3058981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 573.9276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOBLADE GASTRO",
      "code_information": [
        {
          "code": "3058983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3401.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORTHOLOCK 3X110MM EX",
      "code_information": [
        {
          "code": "3058990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 629.8384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X 343MM",
      "code_information": [
        {
          "code": "3058991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1159,
          "minimum": 243.39,
          "maximum": 848.6198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 780.7302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y935H",
      "code_information": [
        {
          "code": "3059006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.0X40X91MM",
      "code_information": [
        {
          "code": "3059015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.8745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-GENESYS HTA M006580211",
      "code_information": [
        {
          "code": "3059026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6769,
          "minimum": 1421.49,
          "maximum": 4956.2618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4559.7609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-CLEANING STICK 900PT602",
      "code_information": [
        {
          "code": "3059061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.8899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-QUADFUSE 9” EXT SMALLBORE",
      "code_information": [
        {
          "code": "3059062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.1688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED OPT316",
      "code_information": [
        {
          "code": "3059066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 522,
          "minimum": 109.62,
          "maximum": 382.2084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 351.6317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PED 900PT531",
      "code_information": [
        {
          "code": "3059068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 722,
          "minimum": 151.62,
          "maximum": 528.6484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 486.3565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-ABSOLUTE PSI-TEC",
      "code_information": [
        {
          "code": "3059124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-HEADREST SOFTOUCH",
      "code_information": [
        {
          "code": "3059127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ESOPHYX TIF R2007",
      "code_information": [
        {
          "code": "3059129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21712,
          "minimum": 4559.52,
          "maximum": 15897.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14625.7243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTER CONNECT PT-5558-F",
      "code_information": [
        {
          "code": "3059131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 3.5X195 700353",
      "code_information": [
        {
          "code": "3059137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1228,
          "minimum": 257.88,
          "maximum": 899.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 827.2103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACQUIRE EUS FND",
      "code_information": [
        {
          "code": "3059156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 2.0MM BIT",
      "code_information": [
        {
          "code": "3059170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2114,
          "minimum": 443.94,
          "maximum": 1547.8708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1424.0411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-IMPLANT SIZING SG - x",
      "code_information": [
        {
          "code": "3059171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIALYZER-HIGH FLUX 1.6 720DH16",
      "code_information": [
        {
          "code": "3059177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ULTRAPERC FULL 100/573/000",
      "code_information": [
        {
          "code": "3059178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1545,
          "minimum": 324.45,
          "maximum": 1131.249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1040.7491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT MED",
      "code_information": [
        {
          "code": "3059179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENVEO PRO LOADING",
      "code_information": [
        {
          "code": "3059185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2618,
          "minimum": 549.78,
          "maximum": 1916.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1763.5476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 1.5MM NEEDLES",
      "code_information": [
        {
          "code": "3059187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 460,
          "minimum": 96.6,
          "maximum": 336.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 309.867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN 5X5CM FUD021",
      "code_information": [
        {
          "code": "3059209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-KNOTLESS S-TAK STEP 3MM",
      "code_information": [
        {
          "code": "3059213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW OSC SAGITTAL xxMM",
      "code_information": [
        {
          "code": "3059220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 420.3414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO DURACLIP 235CM 11MM",
      "code_information": [
        {
          "code": "3059232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 949.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-HEEL PRESSURE MDT825",
      "code_information": [
        {
          "code": "3059240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT LG",
      "code_information": [
        {
          "code": "3059245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT SM",
      "code_information": [
        {
          "code": "3059246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-POLAR COMBO 1232PP",
      "code_information": [
        {
          "code": "3059252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 907,
          "minimum": 190.47,
          "maximum": 664.1054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-TRI STAPLE 2.0 SIG30AVM",
      "code_information": [
        {
          "code": "3059259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2871,
          "minimum": 602.91,
          "maximum": 2102.1462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1933.9745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND 1.0MM",
      "code_information": [
        {
          "code": "3059273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 860.2178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION LARGE",
      "code_information": [
        {
          "code": "3059275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 183.2257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION MED",
      "code_information": [
        {
          "code": "3059281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 279,
          "minimum": 58.59,
          "maximum": 204.2838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 187.9411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 15\\\" ADJ ILIO",
      "code_information": [
        {
          "code": "3059288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 328,
          "minimum": 68.88,
          "maximum": 240.1616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 220.9487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP ALL",
      "code_information": [
        {
          "code": "3059603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT 111645",
      "code_information": [
        {
          "code": "3059922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 524.7531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X140 143140",
      "code_information": [
        {
          "code": "3059924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1195,
          "minimum": 250.95,
          "maximum": 874.979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 804.9807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LIGASURE SM  LF1212A",
      "code_information": [
        {
          "code": "3059951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3010,
          "minimum": 632.1,
          "maximum": 2203.922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2027.6082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-LEVER EDGE    4100-01",
      "code_information": [
        {
          "code": "3059965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1454,
          "minimum": 305.34,
          "maximum": 1064.6188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 979.4493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ABC SINGLE FUNCTION",
      "code_information": [
        {
          "code": "3059973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 572.5804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATCHER-STONE WITH TUB 840-750",
      "code_information": [
        {
          "code": "3059984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 825,
          "minimum": 173.25,
          "maximum": 604.065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 555.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP       7-382",
      "code_information": [
        {
          "code": "3059989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ISOLATOR  BIP   OSL2",
      "code_information": [
        {
          "code": "3059996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11959,
          "minimum": 2511.39,
          "maximum": 8756.3798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8055.8694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-LINEAR 60GRN      TX60G",
      "code_information": [
        {
          "code": "3060001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 913,
          "minimum": 191.73,
          "maximum": 668.4986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.0187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM GREEN        XR60G",
      "code_information": [
        {
          "code": "3060002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 550,
          "minimum": 115.5,
          "maximum": 402.71,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 370.4932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE   RC014MIBB",
      "code_information": [
        {
          "code": "3060082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 629.8384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CORONARY PERFUSN 10004",
      "code_information": [
        {
          "code": "3060083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEX IRIS     611.75",
      "code_information": [
        {
          "code": "3060129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 858,
          "minimum": 180.18,
          "maximum": 628.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 577.9694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 8\\\"  7708-000-10",
      "code_information": [
        {
          "code": "3060132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.1916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VESSEL           30003",
      "code_information": [
        {
          "code": "3060134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 101,
          "minimum": 21.21,
          "maximum": 73.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SWANSON SUTURE  11-0675",
      "code_information": [
        {
          "code": "3060151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 668.235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-T-TUBE 16FR       0099830",
      "code_information": [
        {
          "code": "3060199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-RETRACTO 12\\\" 1041",
      "code_information": [
        {
          "code": "3060247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE MEDIUM   9893",
      "code_information": [
        {
          "code": "3060289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.4648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH      SZ5  A0A04",
      "code_information": [
        {
          "code": "3060306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 175.8159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-UNIV     60-6010-001",
      "code_information": [
        {
          "code": "3060315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 363.757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERZ-REFLECTIVE PK   PM 8005",
      "code_information": [
        {
          "code": "3060317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-SPRING CLIP 6MM  CSOFT6",
      "code_information": [
        {
          "code": "3060318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 173.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-SILVERSTEIN PK 1428010",
      "code_information": [
        {
          "code": "3060385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0 CT-2 Z332H",
      "code_information": [
        {
          "code": "3060417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROGRAMMER-TEST STIM 3531",
      "code_information": [
        {
          "code": "3060442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2604,
          "minimum": 546.84,
          "maximum": 1906.6488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1754.1169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MINI HOOK 357501",
      "code_information": [
        {
          "code": "3060443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.9088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 4.0MM 03.000.012S",
      "code_information": [
        {
          "code": "3060451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 745,
          "minimum": 156.45,
          "maximum": 545.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 501.8499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 5.0MM 03.000.015S",
      "code_information": [
        {
          "code": "3060452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 363.757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90X9.5 05.003.126S",
      "code_information": [
        {
          "code": "3060455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 420.3414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 10M",
      "code_information": [
        {
          "code": "3060460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3512,
          "minimum": 737.52,
          "maximum": 2571.4864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2365.7675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT",
      "code_information": [
        {
          "code": "3060472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 5MM PAL-508LL",
      "code_information": [
        {
          "code": "3060475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 498.4818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-FAST FIX 360 KPSC",
      "code_information": [
        {
          "code": "3060478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1344,
          "minimum": 282.24,
          "maximum": 984.0768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 905.3507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU RIGHT 7210424",
      "code_information": [
        {
          "code": "3060485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1334,
          "minimum": 280.14,
          "maximum": 976.7548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 898.6144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU LEFT 7210423",
      "code_information": [
        {
          "code": "3060486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 872.3431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STRT 7210426",
      "code_information": [
        {
          "code": "3060488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 872.3431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.3MM CROSSPIN 62-23333",
      "code_information": [
        {
          "code": "3060489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 984.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STR 7210425",
      "code_information": [
        {
          "code": "3060494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 844.0509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SILICONE 8CM        205108",
      "code_information": [
        {
          "code": "3061090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1750,
          "minimum": 367.5,
          "maximum": 1281.35,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1178.842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-SINGLE HOLE 1877-01-010",
      "code_information": [
        {
          "code": "3062492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2040,
          "minimum": 428.4,
          "maximum": 1493.688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1374.193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-3' EPV100 VENT",
      "code_information": [
        {
          "code": "3068320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.8633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX PEDS MAXP",
      "code_information": [
        {
          "code": "3068323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP VIBRATORY ACAPELLA",
      "code_information": [
        {
          "code": "3068325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 509,
          "minimum": 106.89,
          "maximum": 372.6898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.8746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED W/7' TUBING",
      "code_information": [
        {
          "code": "3068327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BIPAP PERFORMATRAK LARGE",
      "code_information": [
        {
          "code": "3068330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT DUAL LIMB",
      "code_information": [
        {
          "code": "3068331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT CAPNOXYGEN C02-01",
      "code_information": [
        {
          "code": "3068332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT/PED 8’ 58051",
      "code_information": [
        {
          "code": "3068333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.9468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-MYOSURE            40-902",
      "code_information": [
        {
          "code": "3078533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 171,
          "minimum": 35.91,
          "maximum": 125.2062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-DURA           20-xxxx",
      "code_information": [
        {
          "code": "3078541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5964,
          "minimum": 1252.44,
          "maximum": 4366.8408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4017.4935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-DURAL           1314",
      "code_information": [
        {
          "code": "3078593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH INDWELLING SLIT 295-6",
      "code_information": [
        {
          "code": "3078730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1052.2007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-KARLEN BALLOON    CS-01700",
      "code_information": [
        {
          "code": "3078823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML 0797208",
      "code_information": [
        {
          "code": "3078850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.2182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU, DIALYSIS 2.5% 2L 5B9876",
      "code_information": [
        {
          "code": "3078852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 497,
          "minimum": 104.37,
          "maximum": 363.9034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 334.7911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML  07138-09",
      "code_information": [
        {
          "code": "3078858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 51,
          "minimum": 10.71,
          "maximum": 37.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 34.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK E3773-45C",
      "code_information": [
        {
          "code": "3078982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1254,
          "minimum": 263.34,
          "maximum": 918.1788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 844.7245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MAS TLIF LIGHT   3400033",
      "code_information": [
        {
          "code": "3079040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1921.8493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MULTILEAD TRIAL     3013",
      "code_information": [
        {
          "code": "3079055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1144,
          "minimum": 240.24,
          "maximum": 837.6368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 770.6259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.0X13        AR-8400EX",
      "code_information": [
        {
          "code": "3079215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 306.4989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.-X13 AR-8500EX",
      "code_information": [
        {
          "code": "3079228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 305.8253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER        20400161S/10",
      "code_information": [
        {
          "code": "3079240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 206.1289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL G2 TIP 35CM",
      "code_information": [
        {
          "code": "3079250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3329,
          "minimum": 699.09,
          "maximum": 2437.4938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2242.4943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 ABRADER    72201518",
      "code_information": [
        {
          "code": "3079252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 656,
          "minimum": 137.76,
          "maximum": 480.3232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 441.8973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR    72201513",
      "code_information": [
        {
          "code": "3079253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 429.0985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3079254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.8272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5 FULL RADIUS 7205305",
      "code_information": [
        {
          "code": "3079257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 306.4989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-4.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3079259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 FULL RADIUM 7205306",
      "code_information": [
        {
          "code": "3079261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 INCISOR     7205345",
      "code_information": [
        {
          "code": "3079262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL 45CM    NSLG2C45A",
      "code_information": [
        {
          "code": "3079282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3167,
          "minimum": 665.07,
          "maximum": 2318.8774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2133.3672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 36\\\"   HAR36",
      "code_information": [
        {
          "code": "3079285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3146,
          "minimum": 660.66,
          "maximum": 2303.5012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2119.2211,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HS FOCUS 9CM CRVD  HAR9F",
      "code_information": [
        {
          "code": "3079290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2871,
          "minimum": 602.91,
          "maximum": 2102.1462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1933.9745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INPUT 8FR PS    080011",
      "code_information": [
        {
          "code": "3079468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNLER SM-LG    9009-s",
      "code_information": [
        {
          "code": "3079475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 766,
          "minimum": 160.86,
          "maximum": 560.8652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 515.996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-RENAL 20CM      900-123",
      "code_information": [
        {
          "code": "3079482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 291.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-EXT BILATERAL DYNJP8004A",
      "code_information": [
        {
          "code": "3079499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-CORNEAL DISP      E5699",
      "code_information": [
        {
          "code": "3079626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.0778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST-OP XL MALE      1315",
      "code_information": [
        {
          "code": "3079661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909504",
      "code_information": [
        {
          "code": "3079703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11962,
          "minimum": 2512.02,
          "maximum": 8758.5764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8057.8903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5070",
      "code_information": [
        {
          "code": "3079707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3761,
          "minimum": 789.81,
          "maximum": 2753.8042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2533.4999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5071",
      "code_information": [
        {
          "code": "3079709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3761,
          "minimum": 789.81,
          "maximum": 2753.8042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2533.4999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PHACO .9MM  8065-750517",
      "code_information": [
        {
          "code": "3079736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 429,
          "minimum": 90.09,
          "maximum": 314.1138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 288.9847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SMALL VIT PLUS 1",
      "code_information": [
        {
          "code": "3079745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1675,
          "minimum": 351.75,
          "maximum": 1226.435,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1128.3202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STAR            AR-1606",
      "code_information": [
        {
          "code": "3079766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 877,
          "minimum": 184.17,
          "maximum": 642.1394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 590.7682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 12MM        CB12LT",
      "code_information": [
        {
          "code": "3079770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1106,
          "minimum": 232.26,
          "maximum": 809.8132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 745.0281,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM KII          CFS22",
      "code_information": [
        {
          "code": "3079789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-FIBER          AR-7209SN",
      "code_information": [
        {
          "code": "3079790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM KII           CFS02",
      "code_information": [
        {
          "code": "3079791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM THREADED KII CTS22",
      "code_information": [
        {
          "code": "3079792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM THREADED KII  CTS0S",
      "code_information": [
        {
          "code": "3079793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATABLE OVAL",
      "code_information": [
        {
          "code": "3079795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 297,
          "minimum": 62.37,
          "maximum": 217.4634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.0663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SILICONE         400561",
      "code_information": [
        {
          "code": "3079975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 550,
          "minimum": 115.5,
          "maximum": 402.71,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 370.4932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER MINI        1500",
      "code_information": [
        {
          "code": "3079992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 395.4173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER SMALL       1500",
      "code_information": [
        {
          "code": "3079994",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 554,
          "minimum": 116.34,
          "maximum": 405.6388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 373.1877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER PETITE      1500",
      "code_information": [
        {
          "code": "3079996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 395.4173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-AGGRESSIVE 3.5   283315",
      "code_information": [
        {
          "code": "3080062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 385.9866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ULTRA AGGRESSIVE 283325",
      "code_information": [
        {
          "code": "3080067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 385.9866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.5MM AR-1204AS-95",
      "code_information": [
        {
          "code": "3080073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2182,
          "minimum": 458.22,
          "maximum": 1597.6604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1469.8476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 10MM AR-1204AS-100",
      "code_information": [
        {
          "code": "3080074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1469.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.0MM AR1204AS90",
      "code_information": [
        {
          "code": "3080075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1819,
          "minimum": 381.99,
          "maximum": 1331.8718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1225.3221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-OPTIMOLD NASAL   PS1688",
      "code_information": [
        {
          "code": "3080204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3080355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 352,
          "minimum": 73.92,
          "maximum": 257.7344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 237.1156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-EGIA 60 MED   EGIA60AVM",
      "code_information": [
        {
          "code": "3080925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-ENDOCLIP MULTI    ER320",
      "code_information": [
        {
          "code": "3080932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 859,
          "minimum": 180.39,
          "maximum": 628.9598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 578.643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR VASCULAR  TX30V",
      "code_information": [
        {
          "code": "3081085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 647.3527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT 12”",
      "code_information": [
        {
          "code": "3081101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT RIGHT",
      "code_information": [
        {
          "code": "3081102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY RT ANGLE Y PORT 12”",
      "code_information": [
        {
          "code": "3081103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL HEALTHVENT 24HR 97021",
      "code_information": [
        {
          "code": "3081122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.8083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIEDER TS101DC",
      "code_information": [
        {
          "code": "3081129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 594,
          "minimum": 124.74,
          "maximum": 434.9268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 400.1327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-POLYSORB 55      SZ 200",
      "code_information": [
        {
          "code": "3081173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4940,
          "minimum": 1037.4,
          "maximum": 3617.068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3327.7026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN INSORB 2030",
      "code_information": [
        {
          "code": "3081400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 894,
          "minimum": 187.74,
          "maximum": 654.5868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.2199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZS ECS's",
      "code_information": [
        {
          "code": "3081408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1763,
          "minimum": 370.23,
          "maximum": 1290.8686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1187.5991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZ CDHxxA",
      "code_information": [
        {
          "code": "3081415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1570,
          "minimum": 329.7,
          "maximum": 1149.554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1057.5897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWER  PLEE60A",
      "code_information": [
        {
          "code": "3081416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2611,
          "minimum": 548.31,
          "maximum": 1911.7742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1758.8323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWERED PCE60A",
      "code_information": [
        {
          "code": "3081432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2475,
          "minimum": 519.75,
          "maximum": 1812.195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1667.2194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 45       EC45A",
      "code_information": [
        {
          "code": "3081433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2038,
          "minimum": 427.98,
          "maximum": 1492.2236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1372.8457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 60       EC60A",
      "code_information": [
        {
          "code": "3081436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2635,
          "minimum": 553.35,
          "maximum": 1929.347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1774.9992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-EGIA HANDLE  EGIAUSTND",
      "code_information": [
        {
          "code": "3081443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2985,
          "minimum": 626.85,
          "maximum": 2185.617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2010.7676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDO GIA UNIVER 030449",
      "code_information": [
        {
          "code": "3081491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1778.3674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-THICK TISSUE      TRT75",
      "code_information": [
        {
          "code": "3081494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3081502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT STR 35WD",
      "code_information": [
        {
          "code": "3081503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAYS-SURGICAL PACK    3311-8G",
      "code_information": [
        {
          "code": "3081506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER   TLC-75",
      "code_information": [
        {
          "code": "3081530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 60BL      TX60B",
      "code_information": [
        {
          "code": "3081535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 608.9561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR  40B     CS40B",
      "code_information": [
        {
          "code": "3081542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3019,
          "minimum": 633.99,
          "maximum": 2210.5118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2033.6709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40G      CS40G",
      "code_information": [
        {
          "code": "3081544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3019,
          "minimum": 633.99,
          "maximum": 2210.5118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2033.6709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDOPATH VASC PVE35A",
      "code_information": [
        {
          "code": "3081550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2231,
          "minimum": 468.51,
          "maximum": 1633.5382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1502.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-HEAVY WIRE 90    TLH90",
      "code_information": [
        {
          "code": "3081554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 791,
          "minimum": 166.11,
          "maximum": 579.1702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 532.8366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3081569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A28-2",
      "code_information": [
        {
          "code": "3082047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21603,
          "minimum": 4536.63,
          "maximum": 15817.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14552.2993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A25-25",
      "code_information": [
        {
          "code": "3082066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21603,
          "minimum": 4536.63,
          "maximum": 15817.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14552.2993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-AAA MAIN    ETCF3636C49E",
      "code_information": [
        {
          "code": "3082068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20042,
          "minimum": 4208.82,
          "maximum": 14674.7524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 13500.7722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STICK-FIBER            AR-7209",
      "code_information": [
        {
          "code": "3082089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKINETTE-BARRIER   NON22535",
      "code_information": [
        {
          "code": "3082135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE FOOT        014407",
      "code_information": [
        {
          "code": "3082217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 659,
          "minimum": 138.39,
          "maximum": 482.5198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 443.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRAIGHT           1123",
      "code_information": [
        {
          "code": "3082330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUMP-PERICARDIAL 1/4 CONNECTOR",
      "code_information": [
        {
          "code": "3082395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.9259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURG-STRIP 1/2X6       80-1451",
      "code_information": [
        {
          "code": "3082416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 296,
          "minimum": 62.16,
          "maximum": 216.7312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 199.3927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPRALOOP-BRUCKER/MESSROGHLI",
      "code_information": [
        {
          "code": "3082421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1727,
          "minimum": 362.67,
          "maximum": 1264.5094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1163.3486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-NUKNITT 3X4      1943",
      "code_information": [
        {
          "code": "3082430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC-0       173024",
      "code_information": [
        {
          "code": "3082450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 580.6639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC 2-0 173023",
      "code_information": [
        {
          "code": "3082453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 580.6639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 698G",
      "code_information": [
        {
          "code": "3082542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-GORETEX CV-3      3N06A",
      "code_information": [
        {
          "code": "3082544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 423,
          "minimum": 88.83,
          "maximum": 309.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 284.943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J947H",
      "code_information": [
        {
          "code": "3082558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONO PDSII        Z740D",
      "code_information": [
        {
          "code": "3082562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 305,
          "minimum": 64.05,
          "maximum": 223.321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 205.4553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ALIANCE        5060-05",
      "code_information": [
        {
          "code": "3082566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-FLOSEAL 10ML   1503352",
      "code_information": [
        {
          "code": "3082592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2592,
          "minimum": 544.32,
          "maximum": 1897.8624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1746.0334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING NEMA   3730ANS",
      "code_information": [
        {
          "code": "3082996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2660.1412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ACCESSORY           502",
      "code_information": [
        {
          "code": "3083003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4011,
          "minimum": 842.31,
          "maximum": 2936.8542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2701.9059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BIOGLUE 5ML  BG3515-5US",
      "code_information": [
        {
          "code": "3083007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5122,
          "minimum": 1075.62,
          "maximum": 3750.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3450.3021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANS CATH 10\\\" PM040-A",
      "code_information": [
        {
          "code": "3083014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1368,
          "minimum": 287.28,
          "maximum": 1001.6496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 921.5176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-CYSTO 25X5/8  581610",
      "code_information": [
        {
          "code": "3083019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 50,
          "minimum": 10.5,
          "maximum": 36.61,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 33.6812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE VNUS        CFP",
      "code_information": [
        {
          "code": "3083021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION CATH  PM010-A",
      "code_information": [
        {
          "code": "3083022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 435,
          "minimum": 91.35,
          "maximum": 318.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 293.0264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION 5\\\"    PM020-A",
      "code_information": [
        {
          "code": "3083023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 403.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-COLLECTION   003984-901",
      "code_information": [
        {
          "code": "3083083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.4193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-STERIDRAPE 8 7/8   1075",
      "code_information": [
        {
          "code": "3083104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URETERAL DIAL   240-100",
      "code_information": [
        {
          "code": "3083141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1497,
          "minimum": 314.37,
          "maximum": 1096.1034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1008.4151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-PROTACK DEVICE 5MM",
      "code_information": [
        {
          "code": "3083191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3464,
          "minimum": 727.44,
          "maximum": 2536.3408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2333.4335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB AR-13226",
      "code_information": [
        {
          "code": "3083200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 596,
          "minimum": 125.16,
          "maximum": 436.3912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 401.4799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-BONE SCREW 3.5X50  311.349",
      "code_information": [
        {
          "code": "3083203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.35 2883-02-043",
      "code_information": [
        {
          "code": "3083212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1627.4756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-IQ DISPOSABLE 72-1010",
      "code_information": [
        {
          "code": "3083214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 633.2066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-GLOW AND TELL     1100-20",
      "code_information": [
        {
          "code": "3083225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 376.5558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-          AR-7237-7T",
      "code_information": [
        {
          "code": "3083486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 520,
          "minimum": 109.2,
          "maximum": 380.744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 350.2845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS2",
      "code_information": [
        {
          "code": "3083597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-BIOGLUE FAN        BGST-12",
      "code_information": [
        {
          "code": "3083615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 163.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE ALL    UMx67x's",
      "code_information": [
        {
          "code": "3083622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1067,
          "minimum": 224.07,
          "maximum": 781.2574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 718.7568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 35CM     3908",
      "code_information": [
        {
          "code": "3083637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.9088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CURVED DISP I&A 8065751512",
      "code_information": [
        {
          "code": "3083715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE POLYMER I/A",
      "code_information": [
        {
          "code": "3083720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 222,
          "minimum": 46.62,
          "maximum": 162.5484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-TURBOSONICS     8065750853",
      "code_information": [
        {
          "code": "3083760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 503.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-VACURRETTE 5MM       21664",
      "code_information": [
        {
          "code": "3083764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-TUNNELING            1112",
      "code_information": [
        {
          "code": "3084399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 353.6526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-LUKI MUCOUS SPEC  8646-04",
      "code_information": [
        {
          "code": "3084800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 6",
      "code_information": [
        {
          "code": "3084821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 633.2066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA70",
      "code_information": [
        {
          "code": "3084824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.7529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA80",
      "code_information": [
        {
          "code": "3084827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1345,
          "minimum": 282.45,
          "maximum": 984.809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 906.0243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/METER ALL P4PxxSD",
      "code_information": [
        {
          "code": "3084870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.2523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CHG PREP        DYND70663",
      "code_information": [
        {
          "code": "3084874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.6262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1    4609764",
      "code_information": [
        {
          "code": "3084884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.7381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAPS-FINGER DISP PACK 9900s",
      "code_information": [
        {
          "code": "3084885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 127.9886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-LAP CB EXPLOR    G26908",
      "code_information": [
        {
          "code": "3084925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3560,
          "minimum": 747.6,
          "maximum": 2606.632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2398.1014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SOLU IRRISEPT .5% CHG",
      "code_information": [
        {
          "code": "3084928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 797,
          "minimum": 167.37,
          "maximum": 583.5634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 536.8783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INFLATION   03.804.413S",
      "code_information": [
        {
          "code": "3084946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP 26-23-0757",
      "code_information": [
        {
          "code": "3084992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFF74",
      "code_information": [
        {
          "code": "3085110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-100LP",
      "code_information": [
        {
          "code": "3085111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 906,
          "minimum": 190.26,
          "maximum": 663.3732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.3033,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED     CTF73",
      "code_information": [
        {
          "code": "3085112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-100L",
      "code_information": [
        {
          "code": "3085113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 941,
          "minimum": 197.61,
          "maximum": 689.0002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 633.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREATED      CTF03",
      "code_information": [
        {
          "code": "3085117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-8MM KII OPTICAL   COQ19",
      "code_information": [
        {
          "code": "3085120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR47",
      "code_information": [
        {
          "code": "3085135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR85",
      "code_information": [
        {
          "code": "3085137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM KII OPTICAL  COR37",
      "code_information": [
        {
          "code": "3085140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 567,
          "minimum": 119.07,
          "maximum": 415.1574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.9448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM LONG         C0R39",
      "code_information": [
        {
          "code": "3085142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 567,
          "minimum": 119.07,
          "maximum": 415.1574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.9448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM KII FIOS      CFFxx",
      "code_information": [
        {
          "code": "3085145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM LONG BLADED CFB71",
      "code_information": [
        {
          "code": "3085160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-THORACOPOR 11.5  179303",
      "code_information": [
        {
          "code": "3085163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 882,
          "minimum": 185.22,
          "maximum": 645.8004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 594.1364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM THREADED     CTF33",
      "code_information": [
        {
          "code": "3085165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-SPLIT           82-4095",
      "code_information": [
        {
          "code": "3085170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2007,
          "minimum": 421.47,
          "maximum": 1469.5254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1351.9634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL BLADELESS     B8LT",
      "code_information": [
        {
          "code": "3085202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 482,
          "minimum": 101.22,
          "maximum": 352.9204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 324.6868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP LONG VS101505",
      "code_information": [
        {
          "code": "3085203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1367,
          "minimum": 287.07,
          "maximum": 1000.9174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 920.844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 5MM           B5LT",
      "code_information": [
        {
          "code": "3085207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1543,
          "minimum": 324.03,
          "maximum": 1129.7846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1039.4018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12X100MM     H12LP",
      "code_information": [
        {
          "code": "3085208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 702,
          "minimum": 147.42,
          "maximum": 514.0044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 472.884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN CUFF 7.0MM",
      "code_information": [
        {
          "code": "3085522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BIO PREP BONE PREP",
      "code_information": [
        {
          "code": "3085533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1349,
          "minimum": 283.29,
          "maximum": 987.7378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 908.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SPIKE INFILTRATION",
      "code_information": [
        {
          "code": "3085534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.9259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 8.0FR MEGA IAB",
      "code_information": [
        {
          "code": "3085537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1496,
          "minimum": 314.16,
          "maximum": 1095.3712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1007.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ARMSTRONG TEFLON DRAIN",
      "code_information": [
        {
          "code": "3085540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.2182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-TIBIAL 111651",
      "code_information": [
        {
          "code": "3085541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 286.9638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PROCEDURE TRACKING 107130",
      "code_information": [
        {
          "code": "3085542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.4759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE 111320",
      "code_information": [
        {
          "code": "3085543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 405,
          "minimum": 85.05,
          "maximum": 296.541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 272.8177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX IMPACTION",
      "code_information": [
        {
          "code": "3085544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 817,
          "minimum": 171.57,
          "maximum": 598.2074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 550.3508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144140",
      "code_information": [
        {
          "code": "3085545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 636.5747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX 116230",
      "code_information": [
        {
          "code": "3085546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 633.2066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON ULTRASIL",
      "code_information": [
        {
          "code": "3085560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-ENDO EXCEL 15MM   B15LT",
      "code_information": [
        {
          "code": "3085620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1548,
          "minimum": 325.08,
          "maximum": 1133.4456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1042.77,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR ARMSTRONG    10-56121",
      "code_information": [
        {
          "code": "3085635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.1555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR PAPARELLA 1.14MM",
      "code_information": [
        {
          "code": "3085636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.1555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACHEAL EMG  8229307",
      "code_information": [
        {
          "code": "3085638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1585,
          "minimum": 332.85,
          "maximum": 1160.537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1067.694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH ALL SZS 822970x",
      "code_information": [
        {
          "code": "3085644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1858.5286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 20FR   0100-20",
      "code_information": [
        {
          "code": "3085648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-KAMVAC            5300-00",
      "code_information": [
        {
          "code": "3085723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 594.81,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MOSS GASTROSTOMY  5-17719",
      "code_information": [
        {
          "code": "3085779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1243.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM PROX",
      "code_information": [
        {
          "code": "3085796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 455.3698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T MODIFIED        24-0072",
      "code_information": [
        {
          "code": "3085882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.2124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COLLECTION DISP BKT-506",
      "code_information": [
        {
          "code": "3086006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 203.4344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OXYFLEX        SA008000",
      "code_information": [
        {
          "code": "3086095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX INFLOW  AQL-110",
      "code_information": [
        {
          "code": "3086102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      80-9102",
      "code_information": [
        {
          "code": "3086103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 715,
          "minimum": 150.15,
          "maximum": 523.523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 481.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      5120-10",
      "code_information": [
        {
          "code": "3086105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 154.2599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AIRSEAL ASM-EVAC",
      "code_information": [
        {
          "code": "3086106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 963,
          "minimum": 202.23,
          "maximum": 705.1086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 648.6999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATOR STR  18-95522",
      "code_information": [
        {
          "code": "3086107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 542,
          "minimum": 113.82,
          "maximum": 396.8524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 365.1042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LASER VACUUM    VT10424",
      "code_information": [
        {
          "code": "3086109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LIPOSUCTION   DYND50112",
      "code_information": [
        {
          "code": "3086110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MAIN PUMP       AR-6410",
      "code_information": [
        {
          "code": "3086111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 515.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/4\\\"X1/16\\\"X8'      3108",
      "code_information": [
        {
          "code": "3086139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 132,
          "minimum": 27.72,
          "maximum": 96.6504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.9184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OUTFLOW         AR-6430",
      "code_information": [
        {
          "code": "3086141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO      284508",
      "code_information": [
        {
          "code": "3086142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 450,
          "minimum": 94.5,
          "maximum": 329.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.1308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO IRRIG OUT",
      "code_information": [
        {
          "code": "3086144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-ASPIRATION AT-10003-6",
      "code_information": [
        {
          "code": "3086181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.7039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TISSEEL         0600065",
      "code_information": [
        {
          "code": "3086182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 629,
          "minimum": 132.09,
          "maximum": 460.5538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 423.7095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TRANSDUCER 48 61000",
      "code_information": [
        {
          "code": "3086185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.7457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARTHREX-TIB CANN      AR-1802D",
      "code_information": [
        {
          "code": "3086190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.74,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-& TIP-SMALL   9009-18",
      "code_information": [
        {
          "code": "3086203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 821,
          "minimum": 172.41,
          "maximum": 601.1362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 553.0453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER & TIP-LARGE   9009-16",
      "code_information": [
        {
          "code": "3086205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 724,
          "minimum": 152.04,
          "maximum": 530.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 487.7038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-STIMULATOR LEAD   402",
      "code_information": [
        {
          "code": "3086210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3245,
          "minimum": 681.45,
          "maximum": 2375.989,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2185.9099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE SUPPORT 79-82160",
      "code_information": [
        {
          "code": "3086407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 70x-xxxx ALL SIZES",
      "code_information": [
        {
          "code": "3086409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM VAS          XR30V",
      "code_information": [
        {
          "code": "3086955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 443,
          "minimum": 93.03,
          "maximum": 324.3646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 298.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH 2-0   170057",
      "code_information": [
        {
          "code": "3086965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 813,
          "minimum": 170.73,
          "maximum": 595.2786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 547.6563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VAC-SUPER TURBO     ASC4250-01",
      "code_information": [
        {
          "code": "3087110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 984.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP CVD ALL 21500s",
      "code_information": [
        {
          "code": "3087119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CURVED 7MM     21853",
      "code_information": [
        {
          "code": "3087130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 8MM CVD   20317",
      "code_information": [
        {
          "code": "3087132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VOICE-PROLARYN        8044M0K5",
      "code_information": [
        {
          "code": "3087140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3836,
          "minimum": 805.56,
          "maximum": 2808.7192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2584.0217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVULATOME-LEMAITRE   1009-00",
      "code_information": [
        {
          "code": "3087919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 13534,
          "minimum": 2842.14,
          "maximum": 9909.5948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9116.8272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8916-14",
      "code_information": [
        {
          "code": "3087939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 812,
          "minimum": 170.52,
          "maximum": 594.5464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 546.9827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 UNDYED    VLOCM1904",
      "code_information": [
        {
          "code": "3088955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 364.4306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J761D",
      "code_information": [
        {
          "code": "3088965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.5996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VIOLET    VLOCM0804",
      "code_information": [
        {
          "code": "3088967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 557,
          "minimum": 116.97,
          "maximum": 407.8354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 375.2086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0    MCP496G",
      "code_information": [
        {
          "code": "3088972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J441",
      "code_information": [
        {
          "code": "3088976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS2     1666G",
      "code_information": [
        {
          "code": "3088979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J218H",
      "code_information": [
        {
          "code": "3088985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y495G",
      "code_information": [
        {
          "code": "3088991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.0778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       D5526",
      "code_information": [
        {
          "code": "3088992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 799,
          "minimum": 167.79,
          "maximum": 585.0278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 538.2256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 6-0           Z432H",
      "code_information": [
        {
          "code": "3088993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0  ALL  833-000s",
      "code_information": [
        {
          "code": "3088998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 359.0416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J727D",
      "code_information": [
        {
          "code": "3089002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J905T",
      "code_information": [
        {
          "code": "3089005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J739D",
      "code_information": [
        {
          "code": "3089007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J906G",
      "code_information": [
        {
          "code": "3089013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J740D",
      "code_information": [
        {
          "code": "3089014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J775D",
      "code_information": [
        {
          "code": "3089024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.4743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J789D",
      "code_information": [
        {
          "code": "3089025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 145.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z881G",
      "code_information": [
        {
          "code": "3089026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8806H",
      "code_information": [
        {
          "code": "3089027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z990G",
      "code_information": [
        {
          "code": "3089030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J834G",
      "code_information": [
        {
          "code": "3089039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J833G",
      "code_information": [
        {
          "code": "3089042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8824G",
      "code_information": [
        {
          "code": "3089048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.7438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y493G",
      "code_information": [
        {
          "code": "3089059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y490G",
      "code_information": [
        {
          "code": "3089060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8521H",
      "code_information": [
        {
          "code": "3089064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8581H",
      "code_information": [
        {
          "code": "3089065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.0569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8557H",
      "code_information": [
        {
          "code": "3089066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8833H",
      "code_information": [
        {
          "code": "3089069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8623H",
      "code_information": [
        {
          "code": "3089072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8522H",
      "code_information": [
        {
          "code": "3089073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8534H",
      "code_information": [
        {
          "code": "3089074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J904T",
      "code_information": [
        {
          "code": "3089079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      PX82H",
      "code_information": [
        {
          "code": "3089097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8523H",
      "code_information": [
        {
          "code": "3089100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 60.6262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8706H",
      "code_information": [
        {
          "code": "3089103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.7457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8805H",
      "code_information": [
        {
          "code": "3089105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.2182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8709H",
      "code_information": [
        {
          "code": "3089106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 55.86,
          "maximum": 194.7652,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8720H",
      "code_information": [
        {
          "code": "3089110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.0303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8556H",
      "code_information": [
        {
          "code": "3089113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 61.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8710H",
      "code_information": [
        {
          "code": "3089114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 59.9525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8304H",
      "code_information": [
        {
          "code": "3089117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 240,
          "minimum": 50.4,
          "maximum": 175.728,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 161.6698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8703H",
      "code_information": [
        {
          "code": "3089121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 52.71,
          "maximum": 183.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 169.0796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J213H",
      "code_information": [
        {
          "code": "3089123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO       AR-4068-xxx",
      "code_information": [
        {
          "code": "3089131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 984.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         G124H",
      "code_information": [
        {
          "code": "3089132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         U256H",
      "code_information": [
        {
          "code": "3089133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 2-0       G123H",
      "code_information": [
        {
          "code": "3089145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       1792G",
      "code_information": [
        {
          "code": "3089146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.8576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "3089147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 52.08,
          "maximum": 181.5856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 167.0588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 0       L104G",
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        {
          "code": "3089150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       G172H",
      "code_information": [
        {
          "code": "3089154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U203",
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        {
          "code": "3089156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1637G",
      "code_information": [
        {
          "code": "3089157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0     1916G",
      "code_information": [
        {
          "code": "3089161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     1824H",
      "code_information": [
        {
          "code": "3089172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A304H",
      "code_information": [
        {
          "code": "3089177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 5-0          K890H",
      "code_information": [
        {
          "code": "3089195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           709H",
      "code_information": [
        {
          "code": "3089202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 24.78,
          "maximum": 86.3996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 79.4876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0  X524H",
      "code_information": [
        {
          "code": "3089204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5        B449T",
      "code_information": [
        {
          "code": "3089212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 4-0      X204H",
      "code_information": [
        {
          "code": "3089217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 3-0      X936H",
      "code_information": [
        {
          "code": "3089226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5-0      X727H",
      "code_information": [
        {
          "code": "3089227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        690G",
      "code_information": [
        {
          "code": "3089238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       1666H",
      "code_information": [
        {
          "code": "3089239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1663H",
      "code_information": [
        {
          "code": "3089244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z340H",
      "code_information": [
        {
          "code": "3089254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.7362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 0         L880G",
      "code_information": [
        {
          "code": "3089258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      SXP82",
      "code_information": [
        {
          "code": "3089266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 607,
          "minimum": 127.47,
          "maximum": 444.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 408.8898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND2-0       SXP86",
      "code_information": [
        {
          "code": "3089267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 666,
          "minimum": 139.86,
          "maximum": 487.6452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 448.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X927H",
      "code_information": [
        {
          "code": "3089281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z879G",
      "code_information": [
        {
          "code": "3089283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0 Z494G",
      "code_information": [
        {
          "code": "3089284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.5844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y497G",
      "code_information": [
        {
          "code": "3089286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0        687G",
      "code_information": [
        {
          "code": "3089287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.3207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X513H",
      "code_information": [
        {
          "code": "3089288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.4383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2 MX69G",
      "code_information": [
        {
          "code": "3089290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 145.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS O EZ10G",
      "code_information": [
        {
          "code": "3089291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 260.6925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          EJ10G",
      "code_information": [
        {
          "code": "3089292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 260.6925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       M8720",
      "code_information": [
        {
          "code": "3089293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 622,
          "minimum": 130.62,
          "maximum": 455.4284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 418.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       M8303",
      "code_information": [
        {
          "code": "3089294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 778,
          "minimum": 163.38,
          "maximum": 569.6516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 524.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       U202H",
      "code_information": [
        {
          "code": "3089307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U213H",
      "code_information": [
        {
          "code": "3089308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8843H",
      "code_information": [
        {
          "code": "3089314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.9525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J555G",
      "code_information": [
        {
          "code": "3089316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.9259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            C027D",
      "code_information": [
        {
          "code": "3089318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.1688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX45D",
      "code_information": [
        {
          "code": "3089320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 207,
          "minimum": 43.47,
          "maximum": 151.5654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 139.4402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 8-0         2815G",
      "code_information": [
        {
          "code": "3089323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.7457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X523H",
      "code_information": [
        {
          "code": "3089324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.4383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X977H",
      "code_information": [
        {
          "code": "3089325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 5-0     1915G",
      "code_information": [
        {
          "code": "3089326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.0778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0           Z774D",
      "code_information": [
        {
          "code": "3089328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 203.4344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 10-0      9003G",
      "code_information": [
        {
          "code": "3089335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 174.4686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        793G",
      "code_information": [
        {
          "code": "3089348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.3358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 699G",
      "code_information": [
        {
          "code": "3089354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON/MONO    ETH562H",
      "code_information": [
        {
          "code": "3089357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 CT1  J-945-H",
      "code_information": [
        {
          "code": "3089362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.7362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0        585H",
      "code_information": [
        {
          "code": "3089363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C0125",
      "code_information": [
        {
          "code": "3089364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMD2B413",
      "code_information": [
        {
          "code": "3089371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.9069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPD2B408",
      "code_information": [
        {
          "code": "3089372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       U204H",
      "code_information": [
        {
          "code": "3089379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J428H",
      "code_information": [
        {
          "code": "3089381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 46,
          "minimum": 9.66,
          "maximum": 33.6812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 30.9867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6/0 P-1    J489G",
      "code_information": [
        {
          "code": "3089382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 7-0        J488G",
      "code_information": [
        {
          "code": "3089384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPP1A400",
      "code_information": [
        {
          "code": "3089386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 370,
          "minimum": 77.7,
          "maximum": 270.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.2409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2.0 ALL PX83Hs",
      "code_information": [
        {
          "code": "3089390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1654G",
      "code_information": [
        {
          "code": "3089394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NUROLON 4-0       C584D",
      "code_information": [
        {
          "code": "3089396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 236,
          "minimum": 49.56,
          "maximum": 172.7992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 158.9753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPD2B413",
      "code_information": [
        {
          "code": "3089403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 391,
          "minimum": 82.11,
          "maximum": 286.2902,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 263.387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z493G",
      "code_information": [
        {
          "code": "3089407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN 4-0 1644G",
      "code_information": [
        {
          "code": "3089408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE RS23",
      "code_information": [
        {
          "code": "3089410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC PBT xxMM",
      "code_information": [
        {
          "code": "3089416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 458.7379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1B406",
      "code_information": [
        {
          "code": "3089420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 380,
          "minimum": 79.8,
          "maximum": 278.236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.9771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MONOPTY 16GX20CM",
      "code_information": [
        {
          "code": "3089701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 250.5881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE EICA8875-01",
      "code_information": [
        {
          "code": "3090040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2017,
          "minimum": 423.57,
          "maximum": 1476.8474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1358.6996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-TURBINATE RED EICA4845-01",
      "code_information": [
        {
          "code": "3090049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2053,
          "minimum": 431.13,
          "maximum": 1503.2066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1382.9501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,TOPAZ MICRO ACH4041-0",
      "code_information": [
        {
          "code": "3090061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1808.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .045      WS-1106ST",
      "code_information": [
        {
          "code": "3090191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER #2          AR-7200",
      "code_information": [
        {
          "code": "3091195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER 2-0         AR-7220",
      "code_information": [
        {
          "code": "3091196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5         310.243",
      "code_information": [
        {
          "code": "3091211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 573.9276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.8MM        292.68",
      "code_information": [
        {
          "code": "3091218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 623,
          "minimum": 130.83,
          "maximum": 456.1606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 419.6678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6MM AGK16150",
      "code_information": [
        {
          "code": "3091237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.9088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-2.5MM DRILL XFO082501",
      "code_information": [
        {
          "code": "3091238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE          1806-0080S",
      "code_information": [
        {
          "code": "3091250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1197,
          "minimum": 251.37,
          "maximum": 876.4434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 806.3279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3091317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .054          WS-1406ST",
      "code_information": [
        {
          "code": "3091319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K              0152-0218S",
      "code_information": [
        {
          "code": "3091346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 881,
          "minimum": 185.01,
          "maximum": 645.0682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 593.4627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 040-365",
      "code_information": [
        {
          "code": "3091419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1510,
          "minimum": 317.1,
          "maximum": 1105.622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1017.1722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 046-072",
      "code_information": [
        {
          "code": "3091422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 357,
          "minimum": 74.97,
          "maximum": 261.3954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 240.4838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY    047-032",
      "code_information": [
        {
          "code": "3091425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 295,
          "minimum": 61.95,
          "maximum": 215.999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.7191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE TIP      03.211.410",
      "code_information": [
        {
          "code": "3091436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 616,
          "minimum": 129.36,
          "maximum": 451.0352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 414.9524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 5.0 310.63",
      "code_information": [
        {
          "code": "3091500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3340,
          "minimum": 701.4,
          "maximum": 2445.548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2249.9042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 21665",
      "code_information": [
        {
          "code": "3091501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION SEID",
      "code_information": [
        {
          "code": "3091510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 890,
          "minimum": 186.9,
          "maximum": 651.658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 599.5254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND M 2.5MM 03.000.007S",
      "code_information": [
        {
          "code": "3091511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 533.5102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/2X3/32 /10 3610",
      "code_information": [
        {
          "code": "3091513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 127.9886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLUE-GUN CMS REVOLUTION",
      "code_information": [
        {
          "code": "3091516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1029,
          "minimum": 216.09,
          "maximum": 753.4338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 693.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT 5MM EB210",
      "code_information": [
        {
          "code": "3091517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1537.21,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT FINE EB230",
      "code_information": [
        {
          "code": "3091518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2953,
          "minimum": 620.13,
          "maximum": 2162.1866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1989.2117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE CANNU FLEX .042X12",
      "code_information": [
        {
          "code": "3091560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 379.9239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TEMPORARY CARDIA  024-100",
      "code_information": [
        {
          "code": "3091561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.85,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8MM FIBULA ROD 80-0642",
      "code_information": [
        {
          "code": "3091572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.7529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-FACIAL DENTAL 714-6IN-GEL",
      "code_information": [
        {
          "code": "3093187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 249,
          "minimum": 52.29,
          "maximum": 182.3178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 167.7324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ACCESSORY       3550-02",
      "code_information": [
        {
          "code": "3093195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 633.2066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOBUTTON-CL ULTRA PAC 1.2",
      "code_information": [
        {
          "code": "3094000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2461,
          "minimum": 516.81,
          "maximum": 1801.9442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1657.7887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SNAPFIT 15 DEG    400152",
      "code_information": [
        {
          "code": "3102750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCL0316",
      "code_information": [
        {
          "code": "3115410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 364.4306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCM1545",
      "code_information": [
        {
          "code": "3115420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 364.4306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA ARM        420279",
      "code_information": [
        {
          "code": "3115515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA HEAD       420273",
      "code_information": [
        {
          "code": "3115525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM    420015",
      "code_information": [
        {
          "code": "3115580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT COLUMN 470341",
      "code_information": [
        {
          "code": "3115590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM LONG XI   470358",
      "code_information": [
        {
          "code": "3155025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 253.2826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM XI        470357",
      "code_information": [
        {
          "code": "3155030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 253.2826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 5MM        400161",
      "code_information": [
        {
          "code": "3170005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 8.5-13MM   420206",
      "code_information": [
        {
          "code": "3170007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA            400077",
      "code_information": [
        {
          "code": "3170010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA ENDOWRIST XI",
      "code_information": [
        {
          "code": "3170020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-8MM XI 570361",
      "code_information": [
        {
          "code": "3170050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL s.I.e.    410322",
      "code_information": [
        {
          "code": "3170060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2261.3558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL XI        480322",
      "code_information": [
        {
          "code": "3170070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2261.3558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUB. & FILTER 20400162S/10",
      "code_information": [
        {
          "code": "3171250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 206.1289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-ENDOWRIST STAPLER 45",
      "code_information": [
        {
          "code": "3171320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909506",
      "code_information": [
        {
          "code": "3171350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11962,
          "minimum": 2512.02,
          "maximum": 8758.5764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8057.8903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 12M OMS-T12BT",
      "code_information": [
        {
          "code": "3175750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1756,
          "minimum": 368.76,
          "maximum": 1285.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1182.8837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-SINGLE SITE 8.5    428065",
      "code_information": [
        {
          "code": "3185345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1488,
          "minimum": 312.48,
          "maximum": 1089.5136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1002.3525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEXIBLE         3100A",
      "code_information": [
        {
          "code": "3240013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1449,
          "minimum": 304.29,
          "maximum": 1060.9578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GENERATOR INFANT LP FLOW",
      "code_information": [
        {
          "code": "3240072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 596,
          "minimum": 125.16,
          "maximum": 436.3912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 401.4799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INFANT O2 DELIVERY   RT329",
      "code_information": [
        {
          "code": "3240073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 476,
          "minimum": 99.96,
          "maximum": 348.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 320.645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RESUS S/USE       900RD010",
      "code_information": [
        {
          "code": "3240075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG HYDROGEL",
      "code_information": [
        {
          "code": "3240083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODES-EEG LOW IMPEDENCE",
      "code_information": [
        {
          "code": "3240085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTERFACE-TRACHEOSTOMY HI FLOW",
      "code_information": [
        {
          "code": "3240105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 220.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BELLOWS & WATER TRAP 3100A",
      "code_information": [
        {
          "code": "3240167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CONNECTING TUBING.   3100",
      "code_information": [
        {
          "code": "3240170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.8861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 6 FR    196",
      "code_information": [
        {
          "code": "3249995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.9677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 8 FR    198",
      "code_information": [
        {
          "code": "3249997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.9677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE MAC 5FR    1925",
      "code_information": [
        {
          "code": "3249998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 128.6622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE 14FR 12\\\" 220135",
      "code_information": [
        {
          "code": "3250000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT UNCUFFED",
      "code_information": [
        {
          "code": "3281990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3282370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XS      006950",
      "code_information": [
        {
          "code": "3283013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.9468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP THERAPY  \\\"ACAPELLA\\\"",
      "code_information": [
        {
          "code": "3283015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 238.4629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION  LG     006965",
      "code_information": [
        {
          "code": "3283017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XLG     006970",
      "code_information": [
        {
          "code": "3283018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUVETTE-CO2 DISP ADULT MP01062",
      "code_information": [
        {
          "code": "3284354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 133.3776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER 5MM",
      "code_information": [
        {
          "code": "3290045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL MED HIGH FLOW",
      "code_information": [
        {
          "code": "3290046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.2124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL SM HIGH FLOW",
      "code_information": [
        {
          "code": "3290047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL LG HIGH FLOW",
      "code_information": [
        {
          "code": "3290048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP           23-0757",
      "code_information": [
        {
          "code": "3290060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 204.7817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT L599-130",
      "code_information": [
        {
          "code": "3290061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.4743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT W/MR290 SINGLE",
      "code_information": [
        {
          "code": "3290062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 370,
          "minimum": 77.7,
          "maximum": 270.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.2409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BREATHING NEONATAL",
      "code_information": [
        {
          "code": "3290074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.8975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-INFANT DUAL FLOW RT26",
      "code_information": [
        {
          "code": "3290077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOWMETER-PEAK          002068",
      "code_information": [
        {
          "code": "3290080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-CPAP NASAL NSC-001",
      "code_information": [
        {
          "code": "3290082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.8766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOW-CONT CYSTO GREENLYT",
      "code_information": [
        {
          "code": "3290084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP MED",
      "code_information": [
        {
          "code": "3290127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.9468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP SMALL",
      "code_information": [
        {
          "code": "3290128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.9468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOSE-AIR MODEL 205 DISP",
      "code_information": [
        {
          "code": "3290145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED SM NIV",
      "code_information": [
        {
          "code": "3290170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED MED NIV",
      "code_information": [
        {
          "code": "3290171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED LG NIV",
      "code_information": [
        {
          "code": "3290172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 42MM    RD804-10",
      "code_information": [
        {
          "code": "3290178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP AIRLIFE W/FILTER",
      "code_information": [
        {
          "code": "3290184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL XS INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 309,
          "minimum": 64.89,
          "maximum": 226.2498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.1498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL LG INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL MED INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 191.9828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 308,
          "minimum": 64.68,
          "maximum": 225.5176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 207.4762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 60MM    RD806-10",
      "code_information": [
        {
          "code": "3290194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK,OXY ADULT OM-1125-8",
      "code_information": [
        {
          "code": "3290214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.8899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED SMALL NIV",
      "code_information": [
        {
          "code": "3290215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.5312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 203.4344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED LARGE NIV",
      "code_information": [
        {
          "code": "3290217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.5312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 155.6071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED LG NIV",
      "code_information": [
        {
          "code": "3290219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP ALOHA ALO100",
      "code_information": [
        {
          "code": "3290220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 704,
          "minimum": 147.84,
          "maximum": 515.4688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 474.2313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-MISTY FINITY  002534",
      "code_information": [
        {
          "code": "3290245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 119,
          "minimum": 24.99,
          "maximum": 87.1318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.1613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOPPER-DECANNULATION SZ4",
      "code_information": [
        {
          "code": "3290354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 760,
          "minimum": 159.6,
          "maximum": 556.472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 511.9542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DIRECTIONAL BALLARD  22059",
      "code_information": [
        {
          "code": "3290385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 5MM PROX",
      "code_information": [
        {
          "code": "3290400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 699,
          "minimum": 146.79,
          "maximum": 511.8078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 470.8632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY SLT UNCUFF 5MM",
      "code_information": [
        {
          "code": "3290401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 679,
          "minimum": 142.59,
          "maximum": 497.1638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 457.3907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEST-SPU ALL SZS  WRAP-SLOTTED",
      "code_information": [
        {
          "code": "3290504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 819,
          "minimum": 171.99,
          "maximum": 599.6718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 551.6981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING WHITE    PMV005",
      "code_information": [
        {
          "code": "3290506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 876,
          "minimum": 183.96,
          "maximum": 641.4072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 590.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING PURPLE  PMV2001",
      "code_information": [
        {
          "code": "3290508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 875,
          "minimum": 183.75,
          "maximum": 640.675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 589.421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP LPEEP",
      "code_information": [
        {
          "code": "3290509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP ADJ          2K8082",
      "code_information": [
        {
          "code": "3290515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-THERAPRESSURE     262895",
      "code_information": [
        {
          "code": "3300010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 51,
          "minimum": 10.71,
          "maximum": 37.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 34.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOFT GOODS FOR CPM UNIT",
      "code_information": [
        {
          "code": "3302945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 221.6223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA VARICEX S",
      "code_information": [
        {
          "code": "3310024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-ENDURA KIT         775410",
      "code_information": [
        {
          "code": "3310985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.7172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BGE   A840235",
      "code_information": [
        {
          "code": "3310986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.8766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BLACK  554617",
      "code_information": [
        {
          "code": "3310987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX RED   A840241",
      "code_information": [
        {
          "code": "3310989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 6CMX5CM",
      "code_information": [
        {
          "code": "3310991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 8CMX5CM",
      "code_information": [
        {
          "code": "3310992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 10CMX5M",
      "code_information": [
        {
          "code": "3310993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.8349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDL K 12CMX5M",
      "code_information": [
        {
          "code": "3311000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.9392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL 15CMX.4CMX2.5M",
      "code_information": [
        {
          "code": "3311010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.2523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ12 12CM",
      "code_information": [
        {
          "code": "3311075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 290,
          "minimum": 60.9,
          "maximum": 212.338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 195.351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ7 7CM",
      "code_information": [
        {
          "code": "3311076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL SOFT",
      "code_information": [
        {
          "code": "3311078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING C",
      "code_information": [
        {
          "code": "3311085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AID-\\\"CLEAN EASY\\\" GRIP REACH",
      "code_information": [
        {
          "code": "3311086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.6147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING D",
      "code_information": [
        {
          "code": "3311094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.85,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3311107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-LG HDL      C6298-01-25",
      "code_information": [
        {
          "code": "3311117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 53,
          "minimum": 11.13,
          "maximum": 38.8066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 35.7021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3311123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 6CMX5M",
      "code_information": [
        {
          "code": "3311138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 8CMX5M RL",
      "code_information": [
        {
          "code": "3311139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-IONTOPHOR IOGEL 2971",
      "code_information": [
        {
          "code": "3311144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.8899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYBRESIS PATCH",
      "code_information": [
        {
          "code": "3311150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALU 1.5X3.5 PK 2393",
      "code_information": [
        {
          "code": "3311153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ALUM LTX FREE ALL",
      "code_information": [
        {
          "code": "3311156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.4117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXERCISER-POWER GRIP HAND",
      "code_information": [
        {
          "code": "3311157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.2941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-COMFY HAND/THUMB",
      "code_information": [
        {
          "code": "3311158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 723,
          "minimum": 151.83,
          "maximum": 529.3806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 487.0302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3311161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUTRODE RND 1.25\\\"",
      "code_information": [
        {
          "code": "3311163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT OVAL PK 2\\\"X4\\\"",
      "code_information": [
        {
          "code": "3311164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-WEIGHTED EZ GRIP 920675",
      "code_information": [
        {
          "code": "3311165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELECTRODE ADULT       9050",
      "code_information": [
        {
          "code": "3311167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3311174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT SQ PK  1.5X3.5",
      "code_information": [
        {
          "code": "3311178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.4592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT M&LGE",
      "code_information": [
        {
          "code": "3311191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARD-FOOD INVISIBLE      1115",
      "code_information": [
        {
          "code": "3311192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-TRACTION EXER ALL C5032s",
      "code_information": [
        {
          "code": "3311193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT S&XS",
      "code_information": [
        {
          "code": "3311194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LAVAGE    0210112000",
      "code_information": [
        {
          "code": "3311197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 504,
          "minimum": 105.84,
          "maximum": 369.0288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 339.5065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPM SOFTGOOD FOR HOME UNIT",
      "code_information": [
        {
          "code": "3311235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 221.6223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3311250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.8861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HIP/KNEE W/26 REACHER",
      "code_information": [
        {
          "code": "3311251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH UPPER EXTREMITY",
      "code_information": [
        {
          "code": "3311255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.2941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-ELASTO-GEL CAST/SPL  A8273",
      "code_information": [
        {
          "code": "3311340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 35.0284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3311347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3311357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-D WRIST BRACE ALL SIZES",
      "code_information": [
        {
          "code": "3311363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.4326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADDING-FOAM \\\"KOMPREX\\\" SHEET",
      "code_information": [
        {
          "code": "3311369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPOON-WEIGHTED EZ GRIP 920688",
      "code_information": [
        {
          "code": "3311406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-LONG-32\\\"       A665009",
      "code_information": [
        {
          "code": "3311472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-ALUMINUM 32\\\"      4107",
      "code_information": [
        {
          "code": "3311475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 35.0284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-STANDARD 26\\\"    A80-42",
      "code_information": [
        {
          "code": "3311479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-SAMMONS PRESTON   4109",
      "code_information": [
        {
          "code": "3311480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINTING-EZEFORM 1/8”X18”X24”",
      "code_information": [
        {
          "code": "3311600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 475,
          "minimum": 99.75,
          "maximum": 347.795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELBOW NEOPRENE XL",
      "code_information": [
        {
          "code": "3311602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.8216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-JOINT JACK MED   A52542",
      "code_information": [
        {
          "code": "3311613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.2883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 6\\\"-7\\\"",
      "code_information": [
        {
          "code": "3311625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 3-14",
      "code_information": [
        {
          "code": "3311701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT S/M A812731",
      "code_information": [
        {
          "code": "3311702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 250.5881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND COMFY LG ADULT",
      "code_information": [
        {
          "code": "3311703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 444,
          "minimum": 93.24,
          "maximum": 325.0968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.0891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT/LARGE DYNAPRO",
      "code_information": [
        {
          "code": "3311704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 503.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-STABILIZER WALKER ROLYAN",
      "code_information": [
        {
          "code": "3311708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 463,
          "minimum": 97.23,
          "maximum": 339.0086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 311.8879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WALKER HIGH OVATION LRG",
      "code_information": [
        {
          "code": "3311709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 369.8196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-LMB FINGER HUGGER",
      "code_information": [
        {
          "code": "3312530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 165.0379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EZEFORM-ANTI MICROBIAL 564393",
      "code_information": [
        {
          "code": "3315521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 572,
          "minimum": 120.12,
          "maximum": 418.8184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 385.3129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3397811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 235.0948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PALM SHIELD RIGHT",
      "code_information": [
        {
          "code": "3397815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.8975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND RIGHT/MED A31228",
      "code_information": [
        {
          "code": "3397817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT MED A31227",
      "code_information": [
        {
          "code": "3397818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SYRINGE SSS-STP-SP",
      "code_information": [
        {
          "code": "3500008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.1688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-SKIN DERMABOND  DNX12",
      "code_information": [
        {
          "code": "3500034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.74,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SOFTGOODS CPM        20533",
      "code_information": [
        {
          "code": "3500038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "3500087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LMA DISP ALL SZ  1250xx",
      "code_information": [
        {
          "code": "3500245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 34FR  123034",
      "code_information": [
        {
          "code": "3500275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 28F   123028",
      "code_information": [
        {
          "code": "3500280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 26FR  123026",
      "code_information": [
        {
          "code": "3500283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 30FR  123030",
      "code_information": [
        {
          "code": "3500285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 32FR  123032",
      "code_information": [
        {
          "code": "3500288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACMENT KNEE COLD L/XL",
      "code_information": [
        {
          "code": "3500410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED & 60MM AIRWAY",
      "code_information": [
        {
          "code": "3500786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT & 90MM AIRWY",
      "code_information": [
        {
          "code": "3500788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.4743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASPIRATOR-MECONIUM HCI   N0101",
      "code_information": [
        {
          "code": "3500789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-INFANT  5442160xx",
      "code_information": [
        {
          "code": "3500792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-COLLECTION 4X8 BX     9778",
      "code_information": [
        {
          "code": "3500815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    C0135T",
      "code_information": [
        {
          "code": "3501012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.9525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0        697H",
      "code_information": [
        {
          "code": "3501065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 FS-3  1665G",
      "code_information": [
        {
          "code": "3501070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXTERNAL CSF DRAIN INS8700",
      "code_information": [
        {
          "code": "3501130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 448,
          "minimum": 94.08,
          "maximum": 328.0256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 301.7836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC VERALNK ULTLNK500",
      "code_information": [
        {
          "code": "3501755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 666,
          "minimum": 139.86,
          "maximum": 487.6452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 448.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18FR5CC 0119L18",
      "code_information": [
        {
          "code": "3501790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC       6261",
      "code_information": [
        {
          "code": "3502002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EFFLUENT 5L PRISMAFLEX",
      "code_information": [
        {
          "code": "3502007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.4743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 20F30C  0167L20",
      "code_information": [
        {
          "code": "3502010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL   TCS1000",
      "code_information": [
        {
          "code": "3502048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 369,
          "minimum": 77.49,
          "maximum": 270.1818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 248.5673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 400     7000LL",
      "code_information": [
        {
          "code": "3502063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST MED RIGHT 5001-0",
      "code_information": [
        {
          "code": "3502580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.8007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LARGE RT  5001-04",
      "code_information": [
        {
          "code": "3502590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.8007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-LIFEBAND FOR AUTOPULSE",
      "code_information": [
        {
          "code": "3502593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1266,
          "minimum": 265.86,
          "maximum": 926.9652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 852.808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST X-LG LT 5001-10",
      "code_information": [
        {
          "code": "3502600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.1688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-FLEXMASTER 6\\\" 79-98718",
      "code_information": [
        {
          "code": "3502681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.4952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF C",
      "code_information": [
        {
          "code": "3502706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 547,
          "minimum": 114.87,
          "maximum": 400.5134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 368.4723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF D",
      "code_information": [
        {
          "code": "3502707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 475,
          "minimum": 99.75,
          "maximum": 347.795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-BUNNY W/FRAME & LINER",
      "code_information": [
        {
          "code": "3502709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 351,
          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 236.442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-LEG FULL SM 9128-01",
      "code_information": [
        {
          "code": "3502720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 345,
          "minimum": 72.45,
          "maximum": 252.609,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 232.4003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3502751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.8007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMIN 46-62 13992000",
      "code_information": [
        {
          "code": "3503080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-HOOD ALL  0408-8xx-000",
      "code_information": [
        {
          "code": "3503348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 679,
          "minimum": 142.59,
          "maximum": 497.1638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 457.3907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ENV INFANT   8004-01",
      "code_information": [
        {
          "code": "3503370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT ARM",
      "code_information": [
        {
          "code": "3504148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.8975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT BOOT",
      "code_information": [
        {
          "code": "3504149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.8975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT FULL LENGTH",
      "code_information": [
        {
          "code": "3504150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED ARM",
      "code_information": [
        {
          "code": "3504151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED BOOT",
      "code_information": [
        {
          "code": "3504152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 12\\\" 13960000*",
      "code_information": [
        {
          "code": "3504230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.3207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER EYE        607120",
      "code_information": [
        {
          "code": "3504353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MAC 3&4",
      "code_information": [
        {
          "code": "3504355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.2106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MIL 2&3",
      "code_information": [
        {
          "code": "3504357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.2106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "3504552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1.5\\\" CT\\\"",
      "code_information": [
        {
          "code": "3504553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM      100 1974",
      "code_information": [
        {
          "code": "3504663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 326,
          "minimum": 68.46,
          "maximum": 238.6972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 219.6014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM     12-7 1972",
      "code_information": [
        {
          "code": "3504665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CHANNELED         KVL03C",
      "code_information": [
        {
          "code": "3504905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST EZWALK XL 2001-05",
      "code_information": [
        {
          "code": "3505035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST STAT ALL 2001-00s",
      "code_information": [
        {
          "code": "3505545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA TENDERWRAP 4\\\"X10YDS",
      "code_information": [
        {
          "code": "3505570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WAFFLE  ALL SIZES    FW's",
      "code_information": [
        {
          "code": "3505575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.2883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2515H****",
      "code_information": [
        {
          "code": "3505815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.0569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICAL MED",
      "code_information": [
        {
          "code": "3505906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE HEAVY LARGE",
      "code_information": [
        {
          "code": "3505907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 69.3833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE CHILD   3004-12",
      "code_information": [
        {
          "code": "3505955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION ATEC",
      "code_information": [
        {
          "code": "3506118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.6262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3506181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-7FR \\\"SLIC\\\"       SC-14701",
      "code_information": [
        {
          "code": "3506470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CURITY ULTRAMER 6FR  6006",
      "code_information": [
        {
          "code": "3506758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 22G   383591",
      "code_information": [
        {
          "code": "3507108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 24G   383590",
      "code_information": [
        {
          "code": "3507111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW ARTERIAL VENOUS",
      "code_information": [
        {
          "code": "3507185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.3984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3W 16F 5CC  0119L16",
      "code_information": [
        {
          "code": "3507187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 30CC ALL 123600As",
      "code_information": [
        {
          "code": "3507190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.8975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 12 5 165812",
      "code_information": [
        {
          "code": "3507192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 14 5 165814",
      "code_information": [
        {
          "code": "3507193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 16 5 165816",
      "code_information": [
        {
          "code": "3507194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 18 5 165818",
      "code_information": [
        {
          "code": "3507195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 20 5 165820",
      "code_information": [
        {
          "code": "3507196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 22 5 165822",
      "code_information": [
        {
          "code": "3507197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 24 5 165824",
      "code_information": [
        {
          "code": "3507198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18F 0125RL18",
      "code_information": [
        {
          "code": "3507371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 260,
          "minimum": 54.6,
          "maximum": 190.372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 175.1422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 20F 30C W/V  0125RL20",
      "code_information": [
        {
          "code": "3507373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.3491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 22FR/30CC",
      "code_information": [
        {
          "code": "3507381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 24F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 177.1631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 26F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 20FR 30CC      266720",
      "code_information": [
        {
          "code": "3507665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.4592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 24FR 30CC      266724",
      "code_information": [
        {
          "code": "3507670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3CC   8887603101",
      "code_information": [
        {
          "code": "3507688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W  8F  3CC   8887603085",
      "code_information": [
        {
          "code": "3507852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-OXIMETRY 5 LUMEN  5032805",
      "code_information": [
        {
          "code": "3508302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1222,
          "minimum": 256.62,
          "maximum": 894.7484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 823.1685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SOAKER 1\\\"           PM030",
      "code_information": [
        {
          "code": "3508888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 719,
          "minimum": 150.99,
          "maximum": 526.4518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 484.3357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-20X1.5 RADIO ARTE RA04220",
      "code_information": [
        {
          "code": "3509147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.2523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 16FR  010116",
      "code_information": [
        {
          "code": "3509269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 14FR  010114",
      "code_information": [
        {
          "code": "3509270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN STRAIGHT 18FR",
      "code_information": [
        {
          "code": "3509305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-CHEST DRAIN 9.6FR",
      "code_information": [
        {
          "code": "3509905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 174.4686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP ADJ     AA11",
      "code_information": [
        {
          "code": "3509911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.37,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-LOW TEMP ADJ      AA02",
      "code_information": [
        {
          "code": "3509912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3510001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COA 04273",
      "code_information": [
        {
          "code": "3510002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3510099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.6831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEX 72\\\"   DF47x-6121Z",
      "code_information": [
        {
          "code": "3510143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENTILATOR COAX",
      "code_information": [
        {
          "code": "3510148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLEANSER-BODY FOAMING REMEDY",
      "code_information": [
        {
          "code": "3510305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCLIP-MEDIUM         523800",
      "code_information": [
        {
          "code": "3510401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.9601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL SMALL 710-SMAL",
      "code_information": [
        {
          "code": "3510714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL MEDIUM 710-MED",
      "code_information": [
        {
          "code": "3510715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK PEDI-SELE",
      "code_information": [
        {
          "code": "3510817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL ALL SZ A11500x",
      "code_information": [
        {
          "code": "3510830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3511220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 35.0284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y PRISMAFLEX",
      "code_information": [
        {
          "code": "3511240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.8349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISP F/NEOBLUE COZY",
      "code_information": [
        {
          "code": "3511668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.9525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FOOT PNEU LRG PR  VP520L",
      "code_information": [
        {
          "code": "3511672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.2865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FT PNEU REGULAR PR VP520",
      "code_information": [
        {
          "code": "3511673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.8349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE LTX-FREE   610-002",
      "code_information": [
        {
          "code": "3511677",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT MED LF/ALUM  7703",
      "code_information": [
        {
          "code": "3511781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.7381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-YOUTH LF/ALUM      7702",
      "code_information": [
        {
          "code": "3511795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3511958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 204.7817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB TALL",
      "code_information": [
        {
          "code": "3511962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 204.7817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-WAFFLE 16x16x2  200WCI",
      "code_information": [
        {
          "code": "3512318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FOAM W/COVER    154264",
      "code_information": [
        {
          "code": "3512506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 211,
          "minimum": 44.31,
          "maximum": 154.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.1347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 16-18FR",
      "code_information": [
        {
          "code": "3512575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.7172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.1CM 9231",
      "code_information": [
        {
          "code": "3512760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.9601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.2CM 9232",
      "code_information": [
        {
          "code": "3512761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.2447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ANCHOR PICC LNE PIC0220",
      "code_information": [
        {
          "code": "3512770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 PED PEDI CAP",
      "code_information": [
        {
          "code": "3512773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RESQPOD 029-12-0242-000",
      "code_information": [
        {
          "code": "3512775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 875.7112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FEMOSTOP         11165",
      "code_information": [
        {
          "code": "3512782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.0793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH STABILIZ    DIO120",
      "code_information": [
        {
          "code": "3512792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH SECURMENT VPPDFP",
      "code_information": [
        {
          "code": "3512794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL  SMALL  S-22MM",
      "code_information": [
        {
          "code": "3513121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.37,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL MEDIUM  M-29MM",
      "code_information": [
        {
          "code": "3513123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.4952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-ACCU ANTI-REFLUX INS8401",
      "code_information": [
        {
          "code": "3513202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1657,
          "minimum": 347.97,
          "maximum": 1213.2554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1116.195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST VALVE PNEUMOSTAT",
      "code_information": [
        {
          "code": "3513225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT PRATT        SU130s",
      "code_information": [
        {
          "code": "3513231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE W/ISO BAG    1003",
      "code_information": [
        {
          "code": "3513475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.7438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM SM SIMP CS",
      "code_information": [
        {
          "code": "3514025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 414,
          "minimum": 86.94,
          "maximum": 303.1308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 278.8803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM BRIDGE",
      "code_information": [
        {
          "code": "3514230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 640,
          "minimum": 134.4,
          "maximum": 468.608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 431.1194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-PREVENA 45ML",
      "code_information": [
        {
          "code": "3514251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 367,
          "minimum": 77.07,
          "maximum": 268.7174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 247.22,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC 500ML WITH GEL",
      "code_information": [
        {
          "code": "3514255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 278.2067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO MED",
      "code_information": [
        {
          "code": "3514259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1213,
          "minimum": 254.73,
          "maximum": 888.1586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 817.1059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO SM",
      "code_information": [
        {
          "code": "3514261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYME 4X4 5044",
      "code_information": [
        {
          "code": "3514264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM     10X15CM",
      "code_information": [
        {
          "code": "3514272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 128.6622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5FR   006173P",
      "code_information": [
        {
          "code": "3514812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1649,
          "minimum": 346.29,
          "maximum": 1207.3978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1110.806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-REDIPAK",
      "code_information": [
        {
          "code": "3514819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLOOD        SQ40S",
      "code_information": [
        {
          "code": "3516138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTERLINE-INTUBATED SET 185",
      "code_information": [
        {
          "code": "3516160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-MR 9GX14CM 20MM",
      "code_information": [
        {
          "code": "3518855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2344,
          "minimum": 492.24,
          "maximum": 1716.2768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1578.9747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX16CM",
      "code_information": [
        {
          "code": "3518857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 385.9866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX1xCM",
      "code_information": [
        {
          "code": "3518865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 385.9866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX1xCM",
      "code_information": [
        {
          "code": "3518868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX10CM",
      "code_information": [
        {
          "code": "3518870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 578,
          "minimum": 121.38,
          "maximum": 423.2116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 389.3547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-LARYNGOSCOPE DISP",
      "code_information": [
        {
          "code": "3518940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1962",
      "code_information": [
        {
          "code": "3519300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1034,
          "minimum": 217.14,
          "maximum": 757.0948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 696.5272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS LF ADLT",
      "code_information": [
        {
          "code": "3519395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.5844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUGGER-HEART STERNUM ALL 1000s",
      "code_information": [
        {
          "code": "3519770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 12F 36\\\"",
      "code_information": [
        {
          "code": "3520193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.5711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 20F 5CC",
      "code_information": [
        {
          "code": "3520196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.7381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 22FR 20CC",
      "code_information": [
        {
          "code": "3520199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 156.9544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INHALER-DIAMOND SPACR 107-9830",
      "code_information": [
        {
          "code": "3520701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-INTUBATION ALL Gs",
      "code_information": [
        {
          "code": "3521014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1015,
          "minimum": 213.15,
          "maximum": 743.183,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 683.7284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ALGO HEARING TEST  040546",
      "code_information": [
        {
          "code": "3521438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.2182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BARRIER MINOR PROTECTIVE",
      "code_information": [
        {
          "code": "3521441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.4743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT FEMORAL 111644",
      "code_information": [
        {
          "code": "3521442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 286.9638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACOSTOMY PROC ******",
      "code_information": [
        {
          "code": "3521523",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 207,
          "minimum": 43.47,
          "maximum": 151.5654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 139.4402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH CVP SL       AK-24301",
      "code_information": [
        {
          "code": "3521655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRAINAL ACCESS    INS-5HND",
      "code_information": [
        {
          "code": "3521683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2054,
          "minimum": 431.34,
          "maximum": 1503.9388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1383.6237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DAILY CARE            6638",
      "code_information": [
        {
          "code": "3521745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAINAGE PLEURX    50-7510",
      "code_information": [
        {
          "code": "3521755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 555.0662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DURAPREP SURGICAL     8630",
      "code_information": [
        {
          "code": "3521756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HYPOTHERMIA \\\"KOOL KIT\\\" 900",
      "code_information": [
        {
          "code": "3521917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1792,
          "minimum": 376.32,
          "maximum": 1312.1024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1207.1342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 6FR AK-09601***",
      "code_information": [
        {
          "code": "3521942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 407,
          "minimum": 85.47,
          "maximum": 298.0054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 274.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 8.5 AK-09803CDC",
      "code_information": [
        {
          "code": "3521947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 628,
          "minimum": 131.88,
          "maximum": 459.8216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 423.0359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGAT CONE/TUBE BX  7721",
      "code_information": [
        {
          "code": "3521963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-SARAH 2778 ALL SIZES",
      "code_information": [
        {
          "code": "3522000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 505,
          "minimum": 106.05,
          "maximum": 369.761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 340.1801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-HANNAH 2160 ALL SIZES",
      "code_information": [
        {
          "code": "3522002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 256,
          "minimum": 53.76,
          "maximum": 187.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.4477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K ALL SIZES",
      "code_information": [
        {
          "code": "3522003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 194.0037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LUMBAR PUNCTURE    4011015",
      "code_information": [
        {
          "code": "3522152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.5312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MAC CATH MULTI AK-21242CDC",
      "code_information": [
        {
          "code": "3522182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1364,
          "minimum": 286.44,
          "maximum": 998.7208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 918.8231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 20FR         6820",
      "code_information": [
        {
          "code": "3522270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 475.5785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00568241",
      "code_information": [
        {
          "code": "3522271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 475.5785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KOOL NEONATAL 950",
      "code_information": [
        {
          "code": "3522460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1169,
          "minimum": 245.49,
          "maximum": 855.9418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 787.4665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING ALL",
      "code_information": [
        {
          "code": "3522465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.5711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-MORGAN LTX-FREE    MT2000",
      "code_information": [
        {
          "code": "3522687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 448,
          "minimum": 94.08,
          "maximum": 328.0256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 301.7836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-4-WAY         4238701",
      "code_information": [
        {
          "code": "3523121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND PREMATURE 900643",
      "code_information": [
        {
          "code": "3523139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND MICRO     900644",
      "code_information": [
        {
          "code": "3523140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 50MM    RD805-10",
      "code_information": [
        {
          "code": "3523187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 101,
          "minimum": 21.21,
          "maximum": 73.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MITT-HAND CONTROL PR  M2023V-A",
      "code_information": [
        {
          "code": "3523675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.4193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTRAOSSEOUS ORANGE",
      "code_information": [
        {
          "code": "3523854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATN     ALL 7700's",
      "code_information": [
        {
          "code": "3523864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 286.9638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX11C",
      "code_information": [
        {
          "code": "3525447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X13.8 C1616A",
      "code_information": [
        {
          "code": "3525465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 174.4686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X7.8  C1610A",
      "code_information": [
        {
          "code": "3525466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X7.8  C2010A",
      "code_information": [
        {
          "code": "3525467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "3525468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL STR 17GX4-1/2\\\"",
      "code_information": [
        {
          "code": "3525873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS G04153",
      "code_information": [
        {
          "code": "3525915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 857,
          "minimum": 179.97,
          "maximum": 627.4954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 577.2958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-4   DJ4011X",
      "code_information": [
        {
          "code": "3525924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 165.0379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL PENCAN    333866",
      "code_information": [
        {
          "code": "3525950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX5\\\"    405148",
      "code_information": [
        {
          "code": "3525951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX7\\\"    405149",
      "code_information": [
        {
          "code": "3525960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X22G",
      "code_information": [
        {
          "code": "3525975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 69.3833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X25G",
      "code_information": [
        {
          "code": "3525976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PROBLOC 20X100 HN3S-100",
      "code_information": [
        {
          "code": "3526110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E CATH PLUS 241285-41E",
      "code_information": [
        {
          "code": "3526122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 467,
          "minimum": 98.07,
          "maximum": 341.9374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 314.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POLYLOOP-LIGATING DEVICE HX-40",
      "code_information": [
        {
          "code": "3526123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 650.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PULSAVAC 00-5150-182-00",
      "code_information": [
        {
          "code": "3526127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.8975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL EXTEND 480422",
      "code_information": [
        {
          "code": "3526149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3703,
          "minimum": 777.63,
          "maximum": 2711.3366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2494.4297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-AIRWAY EMMA 17448",
      "code_information": [
        {
          "code": "3526175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.8216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.5/2.8",
      "code_information": [
        {
          "code": "3526179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1520,
          "minimum": 319.2,
          "maximum": 1112.944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1023.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO xxXxxMM 2.0",
      "code_information": [
        {
          "code": "3526182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.8745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 5800-8-125",
      "code_information": [
        {
          "code": "3526187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1120,
          "minimum": 235.2,
          "maximum": 820.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 754.4589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.3MM TWIST QC",
      "code_information": [
        {
          "code": "3526189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT,-NIFOMETER 10-340-03",
      "code_information": [
        {
          "code": "3526194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.3225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-NASAL AUTOMATION MAD300",
      "code_information": [
        {
          "code": "3526195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 70143061",
      "code_information": [
        {
          "code": "3526216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.2941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT BUTTERFLY 240073",
      "code_information": [
        {
          "code": "3526217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER SB4000SA",
      "code_information": [
        {
          "code": "3526218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1162,
          "minimum": 244.02,
          "maximum": 850.8164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 782.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SB4040SC",
      "code_information": [
        {
          "code": "3526219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 874.364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MALLEABLE MS4000SC",
      "code_information": [
        {
          "code": "3526220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1330,
          "minimum": 279.3,
          "maximum": 973.826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 895.9199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y936H",
      "code_information": [
        {
          "code": "3526223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CANNULATED 2.0X120MM",
      "code_information": [
        {
          "code": "3526239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1136,
          "minimum": 238.56,
          "maximum": 831.7792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 765.2369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICYRL-4-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X36",
      "code_information": [
        {
          "code": "3526256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X96",
      "code_information": [
        {
          "code": "3526257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-0 PDS PLUS 1X60",
      "code_information": [
        {
          "code": "3526258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.0778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 12X18",
      "code_information": [
        {
          "code": "3526259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-4-0 PLUS 1X18",
      "code_information": [
        {
          "code": "3526264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRILL 2.0 SPEED HAND WRIS",
      "code_information": [
        {
          "code": "3526271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1883.4527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM   70890830",
      "code_information": [
        {
          "code": "3526275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM ANTERIOR",
      "code_information": [
        {
          "code": "3526278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 595,
          "minimum": 124.95,
          "maximum": 435.659,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 400.8063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM     70890832",
      "code_information": [
        {
          "code": "3526280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 119,
          "minimum": 24.99,
          "maximum": 87.1318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.1613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT LMA ALL SIZE",
      "code_information": [
        {
          "code": "3526297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURAGAIN SIZE 4",
      "code_information": [
        {
          "code": "3526298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREADED AR-13226T",
      "code_information": [
        {
          "code": "3526314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 930,
          "minimum": 195.3,
          "maximum": 680.946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 626.4703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BATTERY 1.5 50-1010",
      "code_information": [
        {
          "code": "3526343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 919,
          "minimum": 192.99,
          "maximum": 672.8918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 619.0605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL EPISTAX 10CM",
      "code_information": [
        {
          "code": "3526349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 315.9297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC SUPER AK-24301-SK",
      "code_information": [
        {
          "code": "3526356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 684,
          "minimum": 143.64,
          "maximum": 500.8248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 460.7588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY 351-3500SZ",
      "code_information": [
        {
          "code": "3526357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 946,
          "minimum": 198.66,
          "maximum": 692.6612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 637.2483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 115” Y 1637101",
      "code_information": [
        {
          "code": "3526361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LITHOTOMY DYNJ31774G",
      "code_information": [
        {
          "code": "3526362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 789,
          "minimum": 165.69,
          "maximum": 577.7058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 531.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER CLOSED 4MM STRT",
      "code_information": [
        {
          "code": "3526366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1269,
          "minimum": 266.49,
          "maximum": 929.1618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 854.8289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAL, X",
      "code_information": [
        {
          "code": "3526388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 528,
          "minimum": 110.88,
          "maximum": 386.6016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 355.6735,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAl LG",
      "code_information": [
        {
          "code": "3526389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 528,
          "minimum": 110.88,
          "maximum": 386.6016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 355.6735,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-METATRSAL 20MM",
      "code_information": [
        {
          "code": "3526404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2034.3445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.2X1.8X87MM",
      "code_information": [
        {
          "code": "3526414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CANN 2.2 A-2716",
      "code_information": [
        {
          "code": "3526415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2846,
          "minimum": 597.66,
          "maximum": 2083.8412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1917.1339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 20GX6 405211",
      "code_information": [
        {
          "code": "3526416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.9392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL 7 SP-78107",
      "code_information": [
        {
          "code": "3526419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1023,
          "minimum": 214.83,
          "maximum": 749.0406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 689.1174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BASIC BREAST DYNJ60139",
      "code_information": [
        {
          "code": "3526420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 794.8763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-GEN VASCULAR DYNJ60177",
      "code_information": [
        {
          "code": "3526422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1556,
          "minimum": 326.76,
          "maximum": 1139.3032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1048.1589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC SIE DYNJ905699",
      "code_information": [
        {
          "code": "3526423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1952,
          "minimum": 409.92,
          "maximum": 1429.2544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1314.914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO SHOULDER DYNJ60141",
      "code_information": [
        {
          "code": "3526425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 516.6696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO KNEE DYNJ60140",
      "code_information": [
        {
          "code": "3526428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 413.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-LOW FLOW,DISP PATIENT",
      "code_information": [
        {
          "code": "3526443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 675.6449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HIGH FLOW, DISP PT'",
      "code_information": [
        {
          "code": "3526445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1053,
          "minimum": 221.13,
          "maximum": 771.0066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 709.3261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SMALL PED NASAL OXYGEN",
      "code_information": [
        {
          "code": "3526446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.4383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-PED/ADULT SM – MP1500",
      "code_information": [
        {
          "code": "3526447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.4383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIGH FLOW ADULT MA1700",
      "code_information": [
        {
          "code": "3526449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INFANT OVER THE EAR",
      "code_information": [
        {
          "code": "3526455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORPEDO-4.0MM X13 CM AR-8400T",
      "code_information": [
        {
          "code": "3526458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 930,
          "minimum": 195.3,
          "maximum": 680.946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 626.4703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ABLATOR-ASPIRATING AR-8921",
      "code_information": [
        {
          "code": "3526459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 914.7814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR COLD 10MM Rnd",
      "code_information": [
        {
          "code": "3526467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.2883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-OVAL FLUSH-CUT AR-8550FOS",
      "code_information": [
        {
          "code": "3526471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 530.8157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOLVE-CUT RESIST XL520036000",
      "code_information": [
        {
          "code": "3526473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 555.0662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE/BLACK 1.5MM",
      "code_information": [
        {
          "code": "3526474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-90 DEG APOLLO AR-9811",
      "code_information": [
        {
          "code": "3526476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 914.7814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELITE IRRIG 5407010470",
      "code_information": [
        {
          "code": "3526484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 522.7322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRING-MR EMPOWERCTA",
      "code_information": [
        {
          "code": "3526487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.0929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 12 DPSB 60707010200",
      "code_information": [
        {
          "code": "3526492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 190.6356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPSB 60707010300",
      "code_information": [
        {
          "code": "3526493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPSB 60707010400",
      "code_information": [
        {
          "code": "3526494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 234.4212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPDB 60708010300",
      "code_information": [
        {
          "code": "3526495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 315.9297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TUBING MXB-T",
      "code_information": [
        {
          "code": "3526520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 506,
          "minimum": 106.26,
          "maximum": 370.4932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 340.8537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-FLOTRAX PERFUSION 84\\\" M",
      "code_information": [
        {
          "code": "3526525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2947,
          "minimum": 618.87,
          "maximum": 2157.7934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1985.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT YG-272T",
      "code_information": [
        {
          "code": "3526528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.0303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.5MMX13CM AR-8550EX",
      "code_information": [
        {
          "code": "3526571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 305.8253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BULLET CUTTING 3MM",
      "code_information": [
        {
          "code": "3526591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2519,
          "minimum": 528.99,
          "maximum": 1844.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1696.8589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-BIOPATCH CHG 1”X4MM 4150",
      "code_information": [
        {
          "code": "3526904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-JAW TISSUE ENSEAL LRG",
      "code_information": [
        {
          "code": "3526926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2829,
          "minimum": 594.09,
          "maximum": 2071.3938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1905.6823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT SMALL",
      "code_information": [
        {
          "code": "3526929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 571,
          "minimum": 119.91,
          "maximum": 418.0862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 384.6393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT LARGE",
      "code_information": [
        {
          "code": "3526930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 660,
          "minimum": 138.6,
          "maximum": 483.252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 444.5918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A443",
      "code_information": [
        {
          "code": "3526935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 264.7342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A445",
      "code_information": [
        {
          "code": "3526936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFX 2-0 SXMP1B413",
      "code_information": [
        {
          "code": "3526938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 352,
          "minimum": 73.92,
          "maximum": 257.7344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 237.1156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4FUSION 2.0 CALIBRATED",
      "code_information": [
        {
          "code": "3526943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1113,
          "minimum": 233.73,
          "maximum": 814.9386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 749.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-AFFINITY MANIFOLD 1S85R1",
      "code_information": [
        {
          "code": "3526965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COMP SPEEDARC 11X15X13MM",
      "code_information": [
        {
          "code": "3526978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5134,
          "minimum": 1078.14,
          "maximum": 3759.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3458.3856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7.5CM POST",
      "code_information": [
        {
          "code": "3526995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 608,
          "minimum": 127.68,
          "maximum": 445.1776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 409.5634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING DISP EXT 5450850003",
      "code_information": [
        {
          "code": "3526996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1879,
          "minimum": 394.59,
          "maximum": 1375.8038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1265.7395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINDER-DISP SUCT CAN",
      "code_information": [
        {
          "code": "3526997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 282.2485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIAMETER-STRAIGHT 5450800309",
      "code_information": [
        {
          "code": "3526999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3756,
          "minimum": 788.76,
          "maximum": 2750.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2530.1317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRICOTHYROIDOTOMY EMERGENT",
      "code_information": [
        {
          "code": "3527020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1028,
          "minimum": 215.88,
          "maximum": 752.7016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 692.4855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-2.7MM 311.26",
      "code_information": [
        {
          "code": "3527056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 864,
          "minimum": 181.44,
          "maximum": 632.6208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 582.0111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.15, 1.5MM",
      "code_information": [
        {
          "code": "3527057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.7607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.19, 2.0MM",
      "code_information": [
        {
          "code": "3527058",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 849,
          "minimum": 178.29,
          "maximum": 621.6378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 571.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SUCTION 12.7 HI CAPACITY",
      "code_information": [
        {
          "code": "3527060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X .75”",
      "code_information": [
        {
          "code": "3527066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.35X50X101MM",
      "code_information": [
        {
          "code": "3527084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.8745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-BIOPSY MARQUEE",
      "code_information": [
        {
          "code": "3527097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 524.7531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PICK-VEIN 6541",
      "code_information": [
        {
          "code": "3527102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.0/2.3",
      "code_information": [
        {
          "code": "3527119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1520,
          "minimum": 319.2,
          "maximum": 1112.944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1023.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO",
      "code_information": [
        {
          "code": "3527121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.8745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BRUSH ALGER 0.5MM",
      "code_information": [
        {
          "code": "3527123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.3415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOPATCH-DRESS CHG 1” X 7MM",
      "code_information": [
        {
          "code": "3527124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLENOID DRILL 2.5MM",
      "code_information": [
        {
          "code": "3527142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8074,
          "minimum": 1695.54,
          "maximum": 5911.7828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5438.8402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD WIDE MT-APUW",
      "code_information": [
        {
          "code": "3527145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.9088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLUS-VIVAER ARC DISP CAT500",
      "code_information": [
        {
          "code": "3527147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9026,
          "minimum": 1895.46,
          "maximum": 6608.8372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6080.1302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-KEITH FREE 1827-2.5DC",
      "code_information": [
        {
          "code": "3527159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3MM AR-8930D-13",
      "code_information": [
        {
          "code": "3527163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-GONIO SURG OSIG",
      "code_information": [
        {
          "code": "3527169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO V4608-20",
      "code_information": [
        {
          "code": "3527175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.0569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 3.2X125MM GRAY",
      "code_information": [
        {
          "code": "3527179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1195,
          "minimum": 250.95,
          "maximum": 874.979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 804.9807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-POSEY SECURE INFANT PED",
      "code_information": [
        {
          "code": "3527200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.0397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-INDIGO 140CM CATRXKIT",
      "code_information": [
        {
          "code": "3527201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5471.8478,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPERATOR-C4 PENUMBRA SEPC4",
      "code_information": [
        {
          "code": "3527202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4654,
          "minimum": 977.34,
          "maximum": 3407.6588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3135.0461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENGINE INDIGO IAPS3",
      "code_information": [
        {
          "code": "3527203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1627.4756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VPEP 510",
      "code_information": [
        {
          "code": "3527204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.9088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRVO2-TUBE CHAMBER KIT, 900PT",
      "code_information": [
        {
          "code": "3527205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 730,
          "minimum": 153.3,
          "maximum": 534.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 491.7455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN W/AO 5.0MM",
      "code_information": [
        {
          "code": "3527232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 328.7285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-QUICK CONN DRVR-UQC-T10",
      "code_information": [
        {
          "code": "3527241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1399,
          "minimum": 293.79,
          "maximum": 1024.3478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 942.4,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7X70MM IJS-CDC-2770",
      "code_information": [
        {
          "code": "3527242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1876.0428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERES-PASSIVE 8801075",
      "code_information": [
        {
          "code": "3527246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.3491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.9X10X61MM",
      "code_information": [
        {
          "code": "3527253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.8745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DRILL SELF HOLD",
      "code_information": [
        {
          "code": "3527257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2110,
          "minimum": 443.1,
          "maximum": 1544.942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1421.3466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE 108984",
      "code_information": [
        {
          "code": "3527264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.9031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO MICRO 0",
      "code_information": [
        {
          "code": "3527266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 437.182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3527268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5424,
          "minimum": 1139.04,
          "maximum": 3971.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3653.7366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-STERILE PGH 396985",
      "code_information": [
        {
          "code": "3527269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.9031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-BS IS-1 330834",
      "code_information": [
        {
          "code": "3527270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 7MM, 70X",
      "code_information": [
        {
          "code": "3527281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 476.2522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-301-CG 343586",
      "code_information": [
        {
          "code": "3527282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.9031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIDER TS101DC",
      "code_information": [
        {
          "code": "3527287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 594,
          "minimum": 124.74,
          "maximum": 434.9268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 400.1327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM 7089-0832",
      "code_information": [
        {
          "code": "3527289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 1.27MM",
      "code_information": [
        {
          "code": "3527290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.7798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER DS2C026",
      "code_information": [
        {
          "code": "3527342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4316,
          "minimum": 906.36,
          "maximum": 3160.1752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2907.3612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ALLEN 3.0MM 904-0030",
      "code_information": [
        {
          "code": "3527343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 375,
          "minimum": 78.75,
          "maximum": 274.575,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 252.609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3527395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.9392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAXI-THERM LITE 871*******",
      "code_information": [
        {
          "code": "3527520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-CALAZIME REMEDY 4 OZ",
      "code_information": [
        {
          "code": "3527567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-K SOFT 117464",
      "code_information": [
        {
          "code": "3527806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 60-S FIRM 119291",
      "code_information": [
        {
          "code": "3527807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.9031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-C MEDIUM 342657",
      "code_information": [
        {
          "code": "3527808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-INFANT POSITIONER",
      "code_information": [
        {
          "code": "3527875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.7039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CRM DYNJ62070",
      "code_information": [
        {
          "code": "3527887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 756,
          "minimum": 158.76,
          "maximum": 553.5432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 509.2597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-INFANT FULL BODY",
      "code_information": [
        {
          "code": "3527890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1059,
          "minimum": 222.39,
          "maximum": 775.3998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 713.3678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNCK SLCT980010",
      "code_information": [
        {
          "code": "3527947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-IRR SUCT 5500-573-000",
      "code_information": [
        {
          "code": "3527977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3127,
          "minimum": 656.67,
          "maximum": 2289.5894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2106.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION 5450-851-012",
      "code_information": [
        {
          "code": "3527978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MICRO-IQ 12CM 5500-25S-309",
      "code_information": [
        {
          "code": "3527979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5094,
          "minimum": 1069.74,
          "maximum": 3729.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3431.4407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STD-12CM 5500-25S-307",
      "code_information": [
        {
          "code": "3527980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4754,
          "minimum": 998.34,
          "maximum": 3480.8788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3202.4085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRACUDA-12CM IQ 5500-25S-310",
      "code_information": [
        {
          "code": "3527981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5201,
          "minimum": 1092.21,
          "maximum": 3808.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3503.5184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND ROYLAN RT MED",
      "code_information": [
        {
          "code": "3528086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORTHOSIS-ANKLE FOOT LG",
      "code_information": [
        {
          "code": "3528101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 704,
          "minimum": 147.84,
          "maximum": 515.4688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 474.2313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 30 DPSB 60707010500",
      "code_information": [
        {
          "code": "3529495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 250.5881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPDB 60708010200",
      "code_information": [
        {
          "code": "3529498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 428,
          "minimum": 89.88,
          "maximum": 313.3816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 288.3111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SINGLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 429.0985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST DOUBLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 468,
          "minimum": 98.28,
          "maximum": 342.6696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 315.256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #4     4DCP",
      "code_information": [
        {
          "code": "3533309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #6,8,10 DCP",
      "code_information": [
        {
          "code": "3533315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SKIN TEMP DISP MU11228",
      "code_information": [
        {
          "code": "3533577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.6831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP ISOLETTE    MU12551",
      "code_information": [
        {
          "code": "3533578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.3225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-RECTAL/ESOPH ST     491B",
      "code_information": [
        {
          "code": "3533590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTANT-SKIN REMEDY 2 OZ",
      "code_information": [
        {
          "code": "3536085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-SKIN NO STING    MSC1528",
      "code_information": [
        {
          "code": "3536099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 95.6546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-EYE FOAM       28300",
      "code_information": [
        {
          "code": "3536100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-JP 100ML  SU130-1305",
      "code_information": [
        {
          "code": "3538200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3539345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INITIATION BREAST MILK 673",
      "code_information": [
        {
          "code": "3539346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 356,
          "minimum": 74.76,
          "maximum": 260.6632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.8101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-MANUAL HARMONY 67186S",
      "code_information": [
        {
          "code": "3539347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-BIS QUATTRO    186-0106",
      "code_information": [
        {
          "code": "3541300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 336,
          "minimum": 70.56,
          "maximum": 246.0192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 226.3377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS PED DISP",
      "code_information": [
        {
          "code": "3541324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS ADLT DISP",
      "code_information": [
        {
          "code": "3541325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SKIN HNICU38",
      "code_information": [
        {
          "code": "3541328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.3757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-ACOUSTIC RESPIRATION",
      "code_information": [
        {
          "code": "3541329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 227.0113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RECIP PLATELET     4C-2100",
      "code_information": [
        {
          "code": "3541430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.7798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD FILTRATION   4020005",
      "code_information": [
        {
          "code": "3541446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BURETROL 150ML",
      "code_information": [
        {
          "code": "3541503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 252,
          "minimum": 52.92,
          "maximum": 184.5144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.7532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW RADIAL ARTERY",
      "code_information": [
        {
          "code": "3541912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP Y FOR BLOOD IV  D-100",
      "code_information": [
        {
          "code": "3541945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 573.9276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DIALYZER EXELTRA    5M2119",
      "code_information": [
        {
          "code": "3541947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 292,
          "minimum": 61.32,
          "maximum": 213.8024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 196.6982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3541950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1539,
          "minimum": 323.19,
          "maximum": 1126.8558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1036.7073,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FEMORAL ART  C-PMS-401J-FA",
      "code_information": [
        {
          "code": "3542127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO ALL SZ W/ STABILIZER",
      "code_information": [
        {
          "code": "3542128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1489,
          "minimum": 312.69,
          "maximum": 1090.2458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1003.0261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER HF 1000 PRISMAFLEX",
      "code_information": [
        {
          "code": "3542131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2248,
          "minimum": 472.08,
          "maximum": 1645.9856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1514.3068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION OSTOMY BX 1500H",
      "code_information": [
        {
          "code": "3542454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 110 INFUSION 1635101",
      "code_information": [
        {
          "code": "3542760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.5711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRISMAFLEX TPE2000 114093",
      "code_information": [
        {
          "code": "3542806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2271,
          "minimum": 476.91,
          "maximum": 1662.8262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1529.8001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RADIAL ARTERY C-PMS-301-RA",
      "code_information": [
        {
          "code": "3543008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORACENTESIS      4653-48",
      "code_information": [
        {
          "code": "3543530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TUR IRRIGATION  06543-01",
      "code_information": [
        {
          "code": "3543551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE REPOSITION",
      "code_information": [
        {
          "code": "3543681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 497,
          "minimum": 104.37,
          "maximum": 363.9034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 334.7911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE XL REPOSITION",
      "code_information": [
        {
          "code": "3543685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 533.5102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE SM   2042-01",
      "code_information": [
        {
          "code": "3543730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE LRG  2042-03",
      "code_information": [
        {
          "code": "3543732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-NIPPLE REGULAR   67203S",
      "code_information": [
        {
          "code": "3544003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SEQ COMP KNEE      95xx",
      "code_information": [
        {
          "code": "3544619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.1138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501B",
      "code_information": [
        {
          "code": "3544638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501L",
      "code_information": [
        {
          "code": "3544639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.4952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE   VP501M",
      "code_information": [
        {
          "code": "3544640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530M",
      "code_information": [
        {
          "code": "3544645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530L",
      "code_information": [
        {
          "code": "3544650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM CHILD        8001-01",
      "code_information": [
        {
          "code": "3544659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ELEVATOR     8011-02",
      "code_information": [
        {
          "code": "3544860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.1688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE ALL SZS TX4442-0x",
      "code_information": [
        {
          "code": "3545160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.2239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE PED       9007-00",
      "code_information": [
        {
          "code": "3545177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 3L   5B9858",
      "code_information": [
        {
          "code": "3545500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 539,
          "minimum": 113.19,
          "maximum": 394.6558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 363.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 3L  5B9859",
      "code_information": [
        {
          "code": "3545502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 557,
          "minimum": 116.97,
          "maximum": 407.8354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 375.2086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 2L  5B9896",
      "code_information": [
        {
          "code": "3545504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 337.4856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 2L   5B9876",
      "code_information": [
        {
          "code": "3545505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.7627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIAL 1.5% 3L       5B9857",
      "code_information": [
        {
          "code": "3545515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 529,
          "minimum": 111.09,
          "maximum": 387.3338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 356.3471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 1000ML  07139-09",
      "code_information": [
        {
          "code": "3545555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 2000ML  07973-07",
      "code_information": [
        {
          "code": "3545613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 145.5028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-GYLCINE 1.5% IRRIG 3000ML",
      "code_information": [
        {
          "code": "3545747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML  07972-08",
      "code_information": [
        {
          "code": "3545751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 3000ML 07828-08",
      "code_information": [
        {
          "code": "3545752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML R5200-01",
      "code_information": [
        {
          "code": "3545753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 1000ML 07953-09",
      "code_information": [
        {
          "code": "3545755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.6262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-MDI ADAPTER INLINE",
      "code_information": [
        {
          "code": "3545901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.0MM 2883-02-040",
      "code_information": [
        {
          "code": "3547925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3419.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-BENDING 03.501.072",
      "code_information": [
        {
          "code": "3547929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1032,
          "minimum": 216.72,
          "maximum": 755.6304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 695.18,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 650.010",
      "code_information": [
        {
          "code": "3547941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM 60XL",
      "code_information": [
        {
          "code": "3547946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 455.3698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIXER-CEMENT 3CC 658.969S",
      "code_information": [
        {
          "code": "3547948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.601S",
      "code_information": [
        {
          "code": "3547949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2034.3445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ULTRA ACCESS 658.902S",
      "code_information": [
        {
          "code": "3547952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5359,
          "minimum": 1125.39,
          "maximum": 3923.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3609.951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC M6275009/10",
      "code_information": [
        {
          "code": "3547958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-QUILL 2-0 YA-2034Q",
      "code_information": [
        {
          "code": "3547961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 336,
          "minimum": 70.56,
          "maximum": 246.0192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 226.3377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-4-0 PROLENE 8526H",
      "code_information": [
        {
          "code": "3547969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.6262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT",
      "code_information": [
        {
          "code": "3547970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 455.3698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX",
      "code_information": [
        {
          "code": "3547971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 398,
          "minimum": 83.58,
          "maximum": 291.4156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 268.1024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY UNCUFF",
      "code_information": [
        {
          "code": "3547972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 388.0074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 2MM AR-7523",
      "code_information": [
        {
          "code": "3547986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-ZONE NAVIGATOR AR-7900",
      "code_information": [
        {
          "code": "3547987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 650.112",
      "code_information": [
        {
          "code": "3547990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX CN",
      "code_information": [
        {
          "code": "3547997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 328.7285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX UN",
      "code_information": [
        {
          "code": "3547998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 402,
          "minimum": 84.42,
          "maximum": 294.3444,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 270.7968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SHILEY",
      "code_information": [
        {
          "code": "3547999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY CUFFED",
      "code_information": [
        {
          "code": "3548000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 671,
          "minimum": 140.91,
          "maximum": 491.3062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 452.0017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED  4LPC",
      "code_information": [
        {
          "code": "3548001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 626,
          "minimum": 131.46,
          "maximum": 458.3572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 421.6886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ4 S",
      "code_information": [
        {
          "code": "3548003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 81.5085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-TRACH 15MM DECANN WHITE",
      "code_information": [
        {
          "code": "3548004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-TRACH SZ 1 DECANN SH",
      "code_information": [
        {
          "code": "3548005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED",
      "code_information": [
        {
          "code": "3548006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 780,
          "minimum": 163.8,
          "maximum": 571.116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 525.4267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY FLEX INNER",
      "code_information": [
        {
          "code": "3548007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ1",
      "code_information": [
        {
          "code": "3548009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 81.5085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FLUENT DISP FLT-112",
      "code_information": [
        {
          "code": "3548028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1739,
          "minimum": 365.19,
          "maximum": 1273.2958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1171.4321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRESSING CHANGE 76681",
      "code_information": [
        {
          "code": "3549001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 275,
          "minimum": 57.75,
          "maximum": 201.355,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.2466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MOMOPTY 20X15 21201",
      "code_information": [
        {
          "code": "3549005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 458,
          "minimum": 96.18,
          "maximum": 335.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 308.5198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEELIFT-AFO  081531532",
      "code_information": [
        {
          "code": "3549018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 842,
          "minimum": 176.82,
          "maximum": 616.5124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 567.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-SUCTION NEURO NST031/25",
      "code_information": [
        {
          "code": "3549020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-SHANK MOD 5",
      "code_information": [
        {
          "code": "3549027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2034.3445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-LORDOTIC 5",
      "code_information": [
        {
          "code": "3549030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1582.3428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KVLAB3C",
      "code_information": [
        {
          "code": "3549037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 108.4535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KCLAB2C",
      "code_information": [
        {
          "code": "3549038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPEN 279726500",
      "code_information": [
        {
          "code": "3549047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3029,
          "minimum": 636.09,
          "maximum": 2217.8338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2040.4071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX ER VALVE REPLACEMEN",
      "code_information": [
        {
          "code": "3549059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.9031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX CATH ACCESS 50-7280",
      "code_information": [
        {
          "code": "3549060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-NAVIGATION 286750210S",
      "code_information": [
        {
          "code": "3549063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1808.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 020 XFR004xxx",
      "code_information": [
        {
          "code": "3549066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2903,
          "minimum": 609.63,
          "maximum": 2125.5766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1955.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL SND1T3 20.5",
      "code_information": [
        {
          "code": "3549069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3401.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-SYNC DISTAL RADIAL, SDRB-",
      "code_information": [
        {
          "code": "3549082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 273.4913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-BASIC HEEL PRESSURE",
      "code_information": [
        {
          "code": "3549107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 227.0113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- LIGHT 03.612.021S",
      "code_information": [
        {
          "code": "3549135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2191,
          "minimum": 460.11,
          "maximum": 1604.2502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1475.9102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LIGHT 03.615.132S",
      "code_information": [
        {
          "code": "3549136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1748,
          "minimum": 367.08,
          "maximum": 1279.8856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1177.4948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 388.175",
      "code_information": [
        {
          "code": "3549150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1078,
          "minimum": 226.38,
          "maximum": 789.3116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 726.1667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 9-0 V449G",
      "code_information": [
        {
          "code": "3549155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.1973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHALANGEAL 20MM",
      "code_information": [
        {
          "code": "3549160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2034.3445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADER-TRIAL DRG 7032ANS",
      "code_information": [
        {
          "code": "3549166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1808.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULAIDE-CPAP SIZE 2, CA102-",
      "code_information": [
        {
          "code": "3549182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.8216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL PRP ABS-10061T",
      "code_information": [
        {
          "code": "3549185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1469.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.021S",
      "code_information": [
        {
          "code": "3549190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2362,
          "minimum": 496.02,
          "maximum": 1729.4564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1591.0999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703713",
      "code_information": [
        {
          "code": "3549201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1139.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TAP 12.5MM 338.17",
      "code_information": [
        {
          "code": "3549204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1800.597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- CANN 6.5MM 702603",
      "code_information": [
        {
          "code": "3549216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2032,
          "minimum": 426.72,
          "maximum": 1487.8304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1368.804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CSG WORLEY STANDARD",
      "code_information": [
        {
          "code": "3549218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1900,
          "minimum": 399,
          "maximum": 1391.18,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1279.8856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-LAT VEIN WORLEY",
      "code_information": [
        {
          "code": "3549219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2264,
          "minimum": 475.44,
          "maximum": 1657.7008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1525.0847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-UNCUFFED 7.0 70XLTUP",
      "code_information": [
        {
          "code": "3549227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 455.3698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.1X87 A-3836",
      "code_information": [
        {
          "code": "3549229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-PCL 2.4MMX10",
      "code_information": [
        {
          "code": "3549231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 923.5385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CROSS PLATE 705172",
      "code_information": [
        {
          "code": "3549243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2762,
          "minimum": 580.02,
          "maximum": 2022.3364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1860.5495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL CPRP ABS-10063",
      "code_information": [
        {
          "code": "3549250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1333.7755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-THREAD LOCK 03.835.009S",
      "code_information": [
        {
          "code": "3549252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1698,
          "minimum": 356.58,
          "maximum": 1243.2756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1143.8136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPEEDGUIDE-T8 2.4/2.7X30MM",
      "code_information": [
        {
          "code": "3549269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2408,
          "minimum": 505.68,
          "maximum": 1763.1376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1622.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEEDGUIDE AO 2.0X30MM",
      "code_information": [
        {
          "code": "3549270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5577,
          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3756.801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 2.1MM",
      "code_information": [
        {
          "code": "3549272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1742,
          "minimum": 365.82,
          "maximum": 1275.4924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1173.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS TRIPLE 91429",
      "code_information": [
        {
          "code": "3549278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 453,
          "minimum": 95.13,
          "maximum": 331.6866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 305.1517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.1X300MM RMT3130",
      "code_information": [
        {
          "code": "3549279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2423,
          "minimum": 508.83,
          "maximum": 1774.1206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1632.191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-2.5 SOLID HT-2502",
      "code_information": [
        {
          "code": "3549283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1013.1305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Y-PORT-20 FR M00580641",
      "code_information": [
        {
          "code": "3549284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.2239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-DHS REAMER 338.13",
      "code_information": [
        {
          "code": "3549287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7319,
          "minimum": 1536.99,
          "maximum": 5358.9718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4930.2541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOAM-BUMP 10X6X6\\\" DYNJBUMP03",
      "code_information": [
        {
          "code": "3549293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 108.4535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-PALM ROLYAN SOFT GEL LT",
      "code_information": [
        {
          "code": "3549295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 246,
          "minimum": 51.66,
          "maximum": 180.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 165.7115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FORCEP SUCTION 9G12R",
      "code_information": [
        {
          "code": "3549304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HUMIDIFIER ATSVII BE-1010",
      "code_information": [
        {
          "code": "3549307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CATH LINE 020378801",
      "code_information": [
        {
          "code": "3549311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM 6149.1035",
      "code_information": [
        {
          "code": "3549338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 650.114",
      "code_information": [
        {
          "code": "3549348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ANGLE 14MM 684.434",
      "code_information": [
        {
          "code": "3549349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2034.3445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5M SHORT 6149.1037",
      "code_information": [
        {
          "code": "3549352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 16MM 650.116",
      "code_information": [
        {
          "code": "3549372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.0793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD BK-IS 109185",
      "code_information": [
        {
          "code": "3549411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.9031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP 2.4MM",
      "code_information": [
        {
          "code": "3549451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 221.6223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB LARGE AR-8970-09",
      "code_information": [
        {
          "code": "3549452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 949.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ADAPTER BIOPSY MAJ-1414",
      "code_information": [
        {
          "code": "3549507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-THUMB SPICA ANY    350S",
      "code_information": [
        {
          "code": "3549700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.5711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUICKCLOT 8X8 4010",
      "code_information": [
        {
          "code": "3549703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 701.2426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-COMFY FINGER",
      "code_information": [
        {
          "code": "3549716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 6 6SIC",
      "code_information": [
        {
          "code": "3549725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.8558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 8 8SIC",
      "code_information": [
        {
          "code": "3549726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.8558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUIKCLOT 5X5 4000",
      "code_information": [
        {
          "code": "3549730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 733,
          "minimum": 153.93,
          "maximum": 536.7026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 493.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOCN0346",
      "code_information": [
        {
          "code": "3549731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 515.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 200 AC-10030100",
      "code_information": [
        {
          "code": "3549732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3289,
          "minimum": 690.69,
          "maximum": 2408.2058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2215.5493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ESOPHAGEAL 100001",
      "code_information": [
        {
          "code": "3549734",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BV175-6 BLUE EPM8743",
      "code_information": [
        {
          "code": "3549735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 607,
          "minimum": 127.47,
          "maximum": 444.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 408.8898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 365 AC-10030110",
      "code_information": [
        {
          "code": "3549736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1740.6444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LONG TUNNELING SC-4254",
      "code_information": [
        {
          "code": "3549742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1356.6787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM 03.010.061",
      "code_information": [
        {
          "code": "3549747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1751,
          "minimum": 367.71,
          "maximum": 1282.0822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1179.5156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 16MM 03.037.002",
      "code_information": [
        {
          "code": "3549748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5189,
          "minimum": 1089.69,
          "maximum": 3799.3858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3495.4349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 6-9MM 03.037.022",
      "code_information": [
        {
          "code": "3549750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3479,
          "minimum": 730.59,
          "maximum": 2547.3238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2343.5379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-BABYFLOW PLUS S DISP MP37",
      "code_information": [
        {
          "code": "3549751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-DISP",
      "code_information": [
        {
          "code": "3549752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.9051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEOMASK-CPAP",
      "code_information": [
        {
          "code": "3549753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.0303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BABUFLOE SZ 4 DISP MP0149",
      "code_information": [
        {
          "code": "3549754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 225,
          "minimum": 47.25,
          "maximum": 164.745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 151.5654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP",
      "code_information": [
        {
          "code": "3549755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.2523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PNEUMOTHORAX G05297",
      "code_information": [
        {
          "code": "3549757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1013,
          "minimum": 212.73,
          "maximum": 741.7186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 682.3811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOURNIQUET-TACTICAL 30-0023",
      "code_information": [
        {
          "code": "3549759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 360,
          "minimum": 75.6,
          "maximum": 263.592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.5046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R001",
      "code_information": [
        {
          "code": "3549765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1740.6444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-A003",
      "code_information": [
        {
          "code": "3549766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2147.5133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-SEATTLE PLUS MP02260",
      "code_information": [
        {
          "code": "3549776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 379.9239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE HINGED DONJOY",
      "code_information": [
        {
          "code": "3549781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 872,
          "minimum": 183.12,
          "maximum": 638.4784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 587.4001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-DISTAL 24MM 03.211.024",
      "code_information": [
        {
          "code": "3549786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1778.3674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PROX 24MM 03.211.124",
      "code_information": [
        {
          "code": "3549787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1778.3674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL SINGLE PK 1",
      "code_information": [
        {
          "code": "3549805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 668.235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROCESSOR-SOUND LINE 90711",
      "code_information": [
        {
          "code": "3549810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-BAHA STORAGE Z342010",
      "code_information": [
        {
          "code": "3549811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-PERFORM REV PERI MWJ126",
      "code_information": [
        {
          "code": "3549818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 675.6449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5X220MM DWD017",
      "code_information": [
        {
          "code": "3549819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 950,
          "minimum": 199.5,
          "maximum": 695.59,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 639.9428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-0xx-000",
      "code_information": [
        {
          "code": "3549839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SHAFT 8X510 0227-8510S",
      "code_information": [
        {
          "code": "3549851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1867,
          "minimum": 392.07,
          "maximum": 1367.0174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1257.656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LOCKING 705078",
      "code_information": [
        {
          "code": "3549854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1563,
          "minimum": 328.23,
          "maximum": 1144.4286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1052.8743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 700354",
      "code_information": [
        {
          "code": "3549867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1228,
          "minimum": 257.88,
          "maximum": 899.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 827.2103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW INFINITY 3600315",
      "code_information": [
        {
          "code": "3549870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 844.0509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.4 G3606010",
      "code_information": [
        {
          "code": "3549873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-STRAIGH TIP 2762-01-0004",
      "code_information": [
        {
          "code": "3549916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2125.2837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR NIM 945NSD2750",
      "code_information": [
        {
          "code": "3549918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAGITTAL 2296-003-155",
      "code_information": [
        {
          "code": "3549927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 2.4 1608-006-147",
      "code_information": [
        {
          "code": "3549928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 751,
          "minimum": 157.71,
          "maximum": 549.8822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 505.8916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 1MM 1608-006-151",
      "code_information": [
        {
          "code": "3549929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 722,
          "minimum": 151.62,
          "maximum": 528.6484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 486.3565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-413S1",
      "code_information": [
        {
          "code": "3549931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 7X15MM 2296-003-103",
      "code_information": [
        {
          "code": "3549932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 350.9581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-111S5",
      "code_information": [
        {
          "code": "3549933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHORT 2.5MM 2296-003-413",
      "code_information": [
        {
          "code": "3549934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 337.4856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48X70MM 2108-197-00S4",
      "code_information": [
        {
          "code": "3549935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X75MM 4125-089-075",
      "code_information": [
        {
          "code": "3549936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 737,
          "minimum": 154.77,
          "maximum": 539.6314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 496.4609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90 4125-097-090",
      "code_information": [
        {
          "code": "3549937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 403.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 13X90MM 4113-119-090",
      "code_information": [
        {
          "code": "3549938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 403.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-119-090",
      "code_information": [
        {
          "code": "3549939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 516.6696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-127-090",
      "code_information": [
        {
          "code": "3549940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 516.6696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-70X12.5MM 0277-096-277",
      "code_information": [
        {
          "code": "3549941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 572,
          "minimum": 120.12,
          "maximum": 418.8184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 385.3129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RECIPR. 0277-096-325",
      "code_information": [
        {
          "code": "3549942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 583,
          "minimum": 122.43,
          "maximum": 426.8726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 392.7228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 6125-119-090",
      "code_information": [
        {
          "code": "3549943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 832,
          "minimum": 174.72,
          "maximum": 609.1904,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 560.4552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-18.5X90.5 2108-382-003",
      "code_information": [
        {
          "code": "3549944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 618,
          "minimum": 129.78,
          "maximum": 452.4996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 416.2996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE,SAW VASC 5400-134-415",
      "code_information": [
        {
          "code": "3549951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 685,
          "minimum": 143.85,
          "maximum": 501.557,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 461.4324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE, SAW 25X90MM 6725-127-09",
      "code_information": [
        {
          "code": "3549952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2047,
          "minimum": 429.87,
          "maximum": 1498.8134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1378.9083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 8MM M0013635",
      "code_information": [
        {
          "code": "3549961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4128,
          "minimum": 866.88,
          "maximum": 3022.5216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2780.7199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SPINAL W/EPI & BUPIV 3338",
      "code_information": [
        {
          "code": "3549962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.6147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-VISTASEAL VSTL35",
      "code_information": [
        {
          "code": "3549965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 819,
          "minimum": 171.99,
          "maximum": 599.6718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 551.6981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SUTURE UCL AR-7715-4.5",
      "code_information": [
        {
          "code": "3549968",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3921,
          "minimum": 823.41,
          "maximum": 2870.9562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2641.2797,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CEMENT MIX 0206-015-000",
      "code_information": [
        {
          "code": "3549999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 379.9239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-75MM 00-5901-020-00",
      "code_information": [
        {
          "code": "3550017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2485,
          "minimum": 521.85,
          "maximum": 1819.517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1673.9556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-TIB 42-5320-064-02",
      "code_information": [
        {
          "code": "3550019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9296,
          "minimum": 1952.16,
          "maximum": 6806.5312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6262.0087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-REVERSED GLEN MWJ004",
      "code_information": [
        {
          "code": "3550025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1356.6787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-PRESS FIT REV DWJ002",
      "code_information": [
        {
          "code": "3550026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1808.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-INTERLOCKING 3MMX4CM M001",
      "code_information": [
        {
          "code": "3550029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2529,
          "minimum": 531.09,
          "maximum": 1851.7338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1703.5951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DSIP RFID EXPIRATORY MP0",
      "code_information": [
        {
          "code": "3550040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.2124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.6X30 SPEED 703894",
      "code_information": [
        {
          "code": "3550046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 937,
          "minimum": 196.77,
          "maximum": 686.0714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 631.1857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC D-BLADE",
      "code_information": [
        {
          "code": "3550048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #3 MILLER",
      "code_information": [
        {
          "code": "3550049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 163.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WALKER-CAM  II 55988503",
      "code_information": [
        {
          "code": "3550050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 701.9162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-2.5X7MM AR-8998DS",
      "code_information": [
        {
          "code": "3550061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 PC-5",
      "code_information": [
        {
          "code": "3550066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 18\\\" PC-3",
      "code_information": [
        {
          "code": "3550067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROS-NASAL SEPTAL ROUND SP1102",
      "code_information": [
        {
          "code": "3550072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1243.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.007.01S",
      "code_information": [
        {
          "code": "3550083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2060,
          "minimum": 432.6,
          "maximum": 1508.332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1387.6654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST ALL SIZE 9105-00s",
      "code_information": [
        {
          "code": "3550085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP LRG 47800100",
      "code_information": [
        {
          "code": "3550087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1311.5459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP REG 47700100",
      "code_information": [
        {
          "code": "3550088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.2443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP SLIM 4760010",
      "code_information": [
        {
          "code": "3550089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.2443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CAN 190MM 03.010.036",
      "code_information": [
        {
          "code": "3550091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3373,
          "minimum": 708.33,
          "maximum": 2469.7106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2272.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-W/F L&L PED ALL 5002s",
      "code_information": [
        {
          "code": "3550092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.6262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 6MMX10CM M00",
      "code_information": [
        {
          "code": "3550094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2529,
          "minimum": 531.09,
          "maximum": 1851.7338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1703.5951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-ANNULOTOMY 675.405S",
      "code_information": [
        {
          "code": "3550111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1808.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-SHIM SS 6133.0326S",
      "code_information": [
        {
          "code": "3550112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-BRILL 3.5 682.108S",
      "code_information": [
        {
          "code": "3550131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 305.8253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.914S",
      "code_information": [
        {
          "code": "3550136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3419.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CT 3.5M 6149.9135",
      "code_information": [
        {
          "code": "3550137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 668.235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIABETIC FOOT CARE 0811748",
      "code_information": [
        {
          "code": "3550156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.1973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 71MM 705506",
      "code_information": [
        {
          "code": "3550158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1223,
          "minimum": 256.83,
          "maximum": 895.4806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 823.8422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X25MM 7005-3325",
      "code_information": [
        {
          "code": "3550159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT RSZ4001S",
      "code_information": [
        {
          "code": "3550168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1333.7755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW 1020-00-000",
      "code_information": [
        {
          "code": "3550179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-C001",
      "code_information": [
        {
          "code": "3550198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 949.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22GX9CM",
      "code_information": [
        {
          "code": "3550200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 273.4913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.8X122 A-3738",
      "code_information": [
        {
          "code": "3550221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIMED RX COUDE 1314ANS",
      "code_information": [
        {
          "code": "3550227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CERV MOBI-C 13X17 MB3375",
      "code_information": [
        {
          "code": "3550228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21902,
          "minimum": 4599.42,
          "maximum": 16036.6444,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14753.7128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPAR 14MM 0024-LDR",
      "code_information": [
        {
          "code": "3550229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1356.6787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYGEN VOCSN PRT-00930",
      "code_information": [
        {
          "code": "3550231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 264.7342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE 2.5MM 694",
      "code_information": [
        {
          "code": "3550236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5953,
          "minimum": 1250.13,
          "maximum": 4358.7866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4010.0837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-T 601.800",
      "code_information": [
        {
          "code": "3550239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3487,
          "minimum": 732.27,
          "maximum": 2553.1814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2348.9269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPANNER-WRENCH 687.509",
      "code_information": [
        {
          "code": "3550240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INSERTER 694.004",
      "code_information": [
        {
          "code": "3550241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4175,
          "minimum": 876.75,
          "maximum": 3056.935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2812.3802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-INSERTER 694.005",
      "code_information": [
        {
          "code": "3550242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2850.1031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-CALIBER GRAPHIC 994.001",
      "code_information": [
        {
          "code": "3550244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14166,
          "minimum": 2974.86,
          "maximum": 10372.3452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9542.5576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARGYLE SHUNT 8888577775",
      "code_information": [
        {
          "code": "3550249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 280.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND A31216",
      "code_information": [
        {
          "code": "3550250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.4648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-MEPITEL 6.8X10",
      "code_information": [
        {
          "code": "3550253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 128.6622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 12FR 1.0CM",
      "code_information": [
        {
          "code": "3550256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 647.3527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-I/A CAPSULGUARD",
      "code_information": [
        {
          "code": "3550264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.8576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE RT SM 70831",
      "code_information": [
        {
          "code": "3550272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 338,
          "minimum": 70.98,
          "maximum": 247.4836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 227.6849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE LT SM 70831",
      "code_information": [
        {
          "code": "3550273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 238.4629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-OSTEOFUZE OF-BMA-11",
      "code_information": [
        {
          "code": "3550274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8800,
          "minimum": 1848,
          "maximum": 6443.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5927.8912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET REUSE",
      "code_information": [
        {
          "code": "3550275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 870,
          "minimum": 182.7,
          "maximum": 637.014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 586.0529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-HEMOSTATIC POWDER 1978",
      "code_information": [
        {
          "code": "3550278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 498.4818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R002",
      "code_information": [
        {
          "code": "3550306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1740.6444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TROCAR THORACIC 24FR SWD",
      "code_information": [
        {
          "code": "3550314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.2542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-INSPIRA BREAST SRM",
      "code_information": [
        {
          "code": "3550331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4485,
          "minimum": 941.85,
          "maximum": 3283.917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3021.2036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP 180-210CC",
      "code_information": [
        {
          "code": "3550332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DEFENDO Y-OPSY 100303",
      "code_information": [
        {
          "code": "3550394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.9525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PUSHLOCK 2.9MM",
      "code_information": [
        {
          "code": "3550395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 775.3412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM",
      "code_information": [
        {
          "code": "3550396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 914.7814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH 8MM 100/897/080",
      "code_information": [
        {
          "code": "3550399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 878,
          "minimum": 184.38,
          "maximum": 642.8716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 591.4419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER 8MM 100/890/080",
      "code_information": [
        {
          "code": "3550400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.6129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 18FR 897518",
      "code_information": [
        {
          "code": "3550406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 195,
          "minimum": 40.95,
          "maximum": 142.779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 131.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-TRIPLE NEEDLE INS-5300",
      "code_information": [
        {
          "code": "3550411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4172,
          "minimum": 876.12,
          "maximum": 3054.7384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2810.3593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPIN W/ADAPTER INS-5910",
      "code_information": [
        {
          "code": "3550414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4906,
          "minimum": 1030.26,
          "maximum": 3592.1732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3304.7993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J556G",
      "code_information": [
        {
          "code": "3550419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0 770G",
      "code_information": [
        {
          "code": "3550420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8695G",
      "code_information": [
        {
          "code": "3550421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STATLOCK-URO FOLEY FOL0105",
      "code_information": [
        {
          "code": "3550423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-REDDIE KNEE XL 08154723",
      "code_information": [
        {
          "code": "3550426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 294.3737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-BACK ROLYANFIT MESH",
      "code_information": [
        {
          "code": "3550427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.8576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-2.3MM PED SCREW 4008-00",
      "code_information": [
        {
          "code": "3550429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER",
      "code_information": [
        {
          "code": "3550432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 434.4875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING RS5200",
      "code_information": [
        {
          "code": "3550447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5472,
          "minimum": 1149.12,
          "maximum": 4006.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3686.0705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-FIXATION LG FP9000L",
      "code_information": [
        {
          "code": "3550448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 394.07,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL",
      "code_information": [
        {
          "code": "3550461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.5823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-PRIME 286750200S",
      "code_information": [
        {
          "code": "3550473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1808.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-MMG 2862-02-108",
      "code_information": [
        {
          "code": "3550480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1175,
          "minimum": 246.75,
          "maximum": 860.335,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 791.5082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STEM 2862-02-204",
      "code_information": [
        {
          "code": "3550481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1582.3428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 03.010.060",
      "code_information": [
        {
          "code": "3550483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1814,
          "minimum": 380.94,
          "maximum": 1328.2108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1221.9539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-120",
      "code_information": [
        {
          "code": "3550487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 678.3394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-120LP",
      "code_information": [
        {
          "code": "3550488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 646.0054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MACY BEDSIDE DELIVERY M",
      "code_information": [
        {
          "code": "3550498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 932,
          "minimum": 195.72,
          "maximum": 682.4104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 627.8176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PRESSURE OPAQUE 50P148",
      "code_information": [
        {
          "code": "3550499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH,MALE EXTERNAL",
      "code_information": [
        {
          "code": "3550511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH PEDIATRIC",
      "code_information": [
        {
          "code": "3550515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.9392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO CF DEL FGS-0635",
      "code_information": [
        {
          "code": "3550530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2212,
          "minimum": 464.52,
          "maximum": 1619.6264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1490.0563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM ST 6149.1036S",
      "code_information": [
        {
          "code": "3550541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 668.235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF MED MDS601MD",
      "code_information": [
        {
          "code": "3550553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.3491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF XL MDS601BD",
      "code_information": [
        {
          "code": "3550555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.7457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT MED MDS620",
      "code_information": [
        {
          "code": "3550556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 257,
          "minimum": 53.97,
          "maximum": 188.1754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 173.1214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT LRG MDS620L",
      "code_information": [
        {
          "code": "3550557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 277,
          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.5938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH MED MDS630MD",
      "code_information": [
        {
          "code": "3550558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 351,
          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 236.442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH LRG MDS630LD",
      "code_information": [
        {
          "code": "3550559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH X-LG MDS630BD",
      "code_information": [
        {
          "code": "3550560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 383,
          "minimum": 80.43,
          "maximum": 280.4326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT 10° TIP MLD-0068",
      "code_information": [
        {
          "code": "3550592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2125.2837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.5X350MM PK6 MLD-0301",
      "code_information": [
        {
          "code": "3550593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 802.2862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-8/13/18MM MLD-0441S",
      "code_information": [
        {
          "code": "3550594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3325.0081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIM-SPIKE BLUNT MLD-0513",
      "code_information": [
        {
          "code": "3550595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1873,
          "minimum": 393.33,
          "maximum": 1371.4106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1261.6978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- DILATOR MLD-0345",
      "code_information": [
        {
          "code": "3550596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 802.2862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153207",
      "code_information": [
        {
          "code": "3550599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-THORACIC TGMR312610",
      "code_information": [
        {
          "code": "3550613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84847,
          "minimum": 17817.87,
          "maximum": 62124.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57154.9755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X12MM 03.501.762",
      "code_information": [
        {
          "code": "3550619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2487,
          "minimum": 522.27,
          "maximum": 1820.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1675.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX16CM",
      "code_information": [
        {
          "code": "3550630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 385.9866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX16CM",
      "code_information": [
        {
          "code": "3550631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICAL SCREW 3603-00-TE",
      "code_information": [
        {
          "code": "3550634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PEDIATRIC YG-232T",
      "code_information": [
        {
          "code": "3550638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 203.4344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT LARGE YG-282T",
      "code_information": [
        {
          "code": "3550639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 128.6622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC 153509",
      "code_information": [
        {
          "code": "3550645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3ML 165810",
      "code_information": [
        {
          "code": "3550646",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-MARKING ROBOTIP INFARED",
      "code_information": [
        {
          "code": "3550649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE F/MRI SQK65VS",
      "code_information": [
        {
          "code": "3550657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE,FLEX FLEX-200-QFT",
      "code_information": [
        {
          "code": "3550658",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 0200-20",
      "code_information": [
        {
          "code": "3550659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 932.2956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE 24F 5CC 0",
      "code_information": [
        {
          "code": "3550665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 170,
          "minimum": 35.7,
          "maximum": 124.474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.5161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ASSEMBLY DISP 83030-1",
      "code_information": [
        {
          "code": "3550668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1576,
          "minimum": 330.96,
          "maximum": 1153.9472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1061.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY 18G ANG 221251",
      "code_information": [
        {
          "code": "3550683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.37,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-BONE 3.8X13CM AR-8380BC",
      "code_information": [
        {
          "code": "3550684",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 530.8157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VS-1 5FR 80CM BEACON TIP",
      "code_information": [
        {
          "code": "3550691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL DETACHMENT RH1",
      "code_information": [
        {
          "code": "3550699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1076.4512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE D9212",
      "code_information": [
        {
          "code": "3550703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1077,
          "minimum": 226.17,
          "maximum": 788.5794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 725.493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SMARTRELEASE ONYX 83030-",
      "code_information": [
        {
          "code": "3550710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1969,
          "minimum": 413.49,
          "maximum": 1441.7018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1326.3657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM 2.3MM 2862-02-201",
      "code_information": [
        {
          "code": "3550713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3171,
          "minimum": 665.91,
          "maximum": 2321.8062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2136.0617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE ULTRASOUND 8’ CVC6",
      "code_information": [
        {
          "code": "3550720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BONE HARVEST 03.404.000S",
      "code_information": [
        {
          "code": "3550737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12726,
          "minimum": 2672.46,
          "maximum": 9317.9772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8572.539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MENISCAL ROOT 71935068",
      "code_information": [
        {
          "code": "3550740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5252,
          "minimum": 1102.92,
          "maximum": 3845.5144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3537.8732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-REAMER",
      "code_information": [
        {
          "code": "3550752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3893,
          "minimum": 817.53,
          "maximum": 2850.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2622.4182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXY ADULT ETCO2 OM-2125-8",
      "code_information": [
        {
          "code": "3550753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXYTYKE INFNT W/7’ TUBING",
      "code_information": [
        {
          "code": "3550754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONET 188MM 1563-00",
      "code_information": [
        {
          "code": "3550760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1356.6787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT INTERSTIM 3560022",
      "code_information": [
        {
          "code": "3550762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1631,
          "minimum": 342.51,
          "maximum": 1194.2182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1098.6807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 3MM BIT DK-300",
      "code_information": [
        {
          "code": "3550765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2326,
          "minimum": 488.46,
          "maximum": 1703.0972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1566.8494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DECOMPRESSION ZZ-0056",
      "code_information": [
        {
          "code": "3550777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.2106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,LASER TRACH",
      "code_information": [
        {
          "code": "3550778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 675.725S",
      "code_information": [
        {
          "code": "3550783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5471.8478,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP THR 1.35M",
      "code_information": [
        {
          "code": "3550793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.74,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0 8762H",
      "code_information": [
        {
          "code": "3550794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (15) 8800966",
      "code_information": [
        {
          "code": "3550803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (5) 8801002",
      "code_information": [
        {
          "code": "3550804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 227.0113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 4.6X220 P99-110-4622",
      "code_information": [
        {
          "code": "3550805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1591,
          "minimum": 334.11,
          "maximum": 1164.9302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1071.7358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110MM 213524",
      "code_information": [
        {
          "code": "3550809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 636.5747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM ADJ 2862-02-200",
      "code_information": [
        {
          "code": "3550815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3171,
          "minimum": 665.91,
          "maximum": 2321.8062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2136.0617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.1X50 M-R 01-7141",
      "code_information": [
        {
          "code": "3550816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1472,
          "minimum": 309.12,
          "maximum": 1077.7984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 991.5745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL EMBOLIZATION PODH1",
      "code_information": [
        {
          "code": "3550822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1076.4512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 AO A-8004.03",
      "code_information": [
        {
          "code": "3550830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1879,
          "minimum": 394.59,
          "maximum": 1375.8038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1265.7395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 16FR PEDS 8016",
      "code_information": [
        {
          "code": "3550842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CLEARCUT 5X13 AR-8500COS",
      "code_information": [
        {
          "code": "3550848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 530.8157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.45MM SM 45303145",
      "code_information": [
        {
          "code": "3550850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAGE-12MM/8° 50/18 LUI81249",
      "code_information": [
        {
          "code": "3550854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 19856,
          "minimum": 4169.76,
          "maximum": 14538.5632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 13375.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-CUSTOM MED PK623984",
      "code_information": [
        {
          "code": "3550856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52648,
          "minimum": 11056.08,
          "maximum": 38548.8656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 35464.9564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BAL RX DC-RYxxxxxx",
      "code_information": [
        {
          "code": "3550857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-R2P MISAGO SXRxxxxxx",
      "code_information": [
        {
          "code": "3550858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4415,
          "minimum": 927.15,
          "maximum": 3232.663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2974.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-METACROSS BD-xxxxxxxx",
      "code_information": [
        {
          "code": "3550859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1850,
          "minimum": 388.5,
          "maximum": 1354.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1246.2044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT F/2.16MM 3560030",
      "code_information": [
        {
          "code": "3550864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-INTERPULSE",
      "code_information": [
        {
          "code": "3550869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.7798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-SKULL MOUNT 9735300",
      "code_information": [
        {
          "code": "3550873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1643,
          "minimum": 345.03,
          "maximum": 1203.0046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1106.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16FR A3",
      "code_information": [
        {
          "code": "3550876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 294.3737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0X150MM 705234",
      "code_information": [
        {
          "code": "3550888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 903,
          "minimum": 189.63,
          "maximum": 661.1766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 608.2825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PERFORATED FUNCTIONAL 0",
      "code_information": [
        {
          "code": "3550898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 194.0037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-HI-SPEED 4X11 1884068HS",
      "code_information": [
        {
          "code": "3550911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2381,
          "minimum": 500.01,
          "maximum": 1743.3682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1603.8987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PROLAPSE HEM3335",
      "code_information": [
        {
          "code": "3550912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2317,
          "minimum": 486.57,
          "maximum": 1696.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1560.7868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM XT SIGTRSB60AXT",
      "code_information": [
        {
          "code": "3550915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3076,
          "minimum": 645.96,
          "maximum": 2252.2472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2072.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM MT SIGTRSB60AMT",
      "code_information": [
        {
          "code": "3550916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1718.4148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3551250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.4743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PRECISE SKIN      DS-5",
      "code_information": [
        {
          "code": "3552655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT  STR 35R",
      "code_information": [
        {
          "code": "3552730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.8558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3552731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3552732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXW35",
      "code_information": [
        {
          "code": "3552737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.2865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKING-COMPRESSION CUSTOM",
      "code_information": [
        {
          "code": "3553701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 403.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-BONE",
      "code_information": [
        {
          "code": "3554025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9164,
          "minimum": 1924.44,
          "maximum": 6709.8808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6173.0903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CLAVICAL ADULT ALL 3001s",
      "code_information": [
        {
          "code": "3554085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "3554974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.6129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3554981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 280.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-1/2\\\"X2\\\" SMALL    1955",
      "code_information": [
        {
          "code": "3555059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 234.4212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2\\\"X14\\\" LARGE     1951",
      "code_information": [
        {
          "code": "3555109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 533.5102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2 X 3 MEDIUM     1953",
      "code_information": [
        {
          "code": "3555158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 489,
          "minimum": 102.69,
          "maximum": 358.0458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 329.4021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP MED  202549",
      "code_information": [
        {
          "code": "3555307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP LG   202636",
      "code_information": [
        {
          "code": "3555315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORIE-XLGE 202612&201352",
      "code_information": [
        {
          "code": "3555323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 493,
          "minimum": 103.53,
          "maximum": 360.9746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 332.0966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       G121H",
      "code_information": [
        {
          "code": "3555374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0 FS-2   636H",
      "code_information": [
        {
          "code": "3555390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.7362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-DEXON           7618-41",
      "code_information": [
        {
          "code": "3556875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 43,
          "minimum": 9.03,
          "maximum": 31.4846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 28.9658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0   1663H",
      "code_information": [
        {
          "code": "3557098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 41,
          "minimum": 8.61,
          "maximum": 30.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 27.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3557628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.7362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 6-0 P1       697G",
      "code_information": [
        {
          "code": "3557898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        698H",
      "code_information": [
        {
          "code": "3557956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        990H",
      "code_information": [
        {
          "code": "3558678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685G",
      "code_information": [
        {
          "code": "3558679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 16,
          "minimum": 3.36,
          "maximum": 11.7152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 10.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1653-G",
      "code_information": [
        {
          "code": "3558947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1663-H",
      "code_information": [
        {
          "code": "3558970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 49,
          "minimum": 10.29,
          "maximum": 35.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 33.0076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0       1667G",
      "code_information": [
        {
          "code": "3558978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 3-0       1669H",
      "code_information": [
        {
          "code": "3558982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4.5MM 080-453",
      "code_information": [
        {
          "code": "3559003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE P99-930-2108",
      "code_information": [
        {
          "code": "3559011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3368,
          "minimum": 707.28,
          "maximum": 2466.0496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2268.7656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND 2.5MM 1882569HS",
      "code_information": [
        {
          "code": "3559015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1938,
          "minimum": 406.98,
          "maximum": 1419.0036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1305.4833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       G695G",
      "code_information": [
        {
          "code": "3559030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1696-G",
      "code_information": [
        {
          "code": "3559036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.5844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON           1698G",
      "code_information": [
        {
          "code": "3559069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM MT SIGTRSB45AMT",
      "code_information": [
        {
          "code": "3559071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2310,
          "minimum": 485.1,
          "maximum": 1691.382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1556.0714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FEMALE EXT PWF-030K",
      "code_information": [
        {
          "code": "3559082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-LONG 4.2MM 703545",
      "code_information": [
        {
          "code": "3559085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3448,
          "minimum": 724.08,
          "maximum": 2524.6256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2322.6556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-5X100MM FIX UNVCA5STF",
      "code_information": [
        {
          "code": "3559095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 156,
          "minimum": 32.76,
          "maximum": 114.2232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.0853,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 15MM ONB15STF",
      "code_information": [
        {
          "code": "3559096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.7627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 5MM ONB5STF",
      "code_information": [
        {
          "code": "3559097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 286,
          "minimum": 60.06,
          "maximum": 209.4092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 192.6565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3559115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 12FR 0200-12L",
      "code_information": [
        {
          "code": "3559117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 932.2956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM CDH29P",
      "code_information": [
        {
          "code": "3559120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2660,
          "minimum": 558.6,
          "maximum": 1947.652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1791.8398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3559142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2143,
          "minimum": 450.03,
          "maximum": 1569.1046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1443.5762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15MM XTHICK SIG60AXT",
      "code_information": [
        {
          "code": "3559150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1896,
          "minimum": 398.16,
          "maximum": 1388.2512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1277.1911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1065832",
      "code_information": [
        {
          "code": "3559158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIAMONDTOUCH IN9152",
      "code_information": [
        {
          "code": "3559159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 632,
          "minimum": 132.72,
          "maximum": 462.7504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 425.7304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN GUARD",
      "code_information": [
        {
          "code": "3559160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1822.1529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLLEVE-SPIN GUARD",
      "code_information": [
        {
          "code": "3559161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1702,
          "minimum": 357.42,
          "maximum": 1246.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1146.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYDROGEL EEG",
      "code_information": [
        {
          "code": "3559175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J493H",
      "code_information": [
        {
          "code": "3559178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0 1635G",
      "code_information": [
        {
          "code": "3559179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J670G",
      "code_information": [
        {
          "code": "3559180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.9259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP497G",
      "code_information": [
        {
          "code": "3559181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 185,
          "minimum": 38.85,
          "maximum": 135.457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 124.6204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPREADER-SILIPOS GEL TOE MED",
      "code_information": [
        {
          "code": "3559185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.5844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-12MM 10*/MD 08.815.242S",
      "code_information": [
        {
          "code": "3559197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 23165,
          "minimum": 4864.65,
          "maximum": 16961.413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 15604.5,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW-ACC BONCH AF541",
      "code_information": [
        {
          "code": "3559228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW,STD BLUE AF541 73-112096",
      "code_information": [
        {
          "code": "3559229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM/MED/LG",
      "code_information": [
        {
          "code": "3559240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 189,
          "minimum": 39.69,
          "maximum": 138.3858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 127.3149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LAMINARIA-#4 MED 60MM 021004",
      "code_information": [
        {
          "code": "3559244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.2MM XS 45303125",
      "code_information": [
        {
          "code": "3559246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD 4033A",
      "code_information": [
        {
          "code": "3559253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X40MM 7005-3340",
      "code_information": [
        {
          "code": "3559254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X60MM 7005-3360",
      "code_information": [
        {
          "code": "3559255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 10G 0306-530-000",
      "code_information": [
        {
          "code": "3559260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 642,
          "minimum": 134.82,
          "maximum": 470.0724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 432.4666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ TRANS 0909-400-500",
      "code_information": [
        {
          "code": "3559261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 471.5368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 1025-011-500",
      "code_information": [
        {
          "code": "3559262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2367,
          "minimum": 497.07,
          "maximum": 1733.1174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1594.468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CEMENT 0306-410-000",
      "code_information": [
        {
          "code": "3559263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 604,
          "minimum": 126.84,
          "maximum": 442.2488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 406.8689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INDIGO SEP12",
      "code_information": [
        {
          "code": "3559264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8101,
          "minimum": 1701.21,
          "maximum": 5931.5522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5457.028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURRETTE-10G 0306-621-000",
      "code_information": [
        {
          "code": "3559265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3257,
          "minimum": 683.97,
          "maximum": 2384.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2193.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FLEX CUFFED",
      "code_information": [
        {
          "code": "3559271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 750,
          "minimum": 157.5,
          "maximum": 549.15,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 505.218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-FLEXIBLE 2.9MM 682.622",
      "code_information": [
        {
          "code": "3559276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1356.6787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2516H",
      "code_information": [
        {
          "code": "3559281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.0569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COILED 60\\\" CT 100113",
      "code_information": [
        {
          "code": "3559287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-GPS 3.5MM 6143.2572",
      "code_information": [
        {
          "code": "3559291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2034.3445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4.2X360/SM 1320-3642S",
      "code_information": [
        {
          "code": "3559293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 646.0054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383593",
      "code_information": [
        {
          "code": "3559297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON BLK 4-0   1854G",
      "code_information": [
        {
          "code": "3559366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 PC-1  1855G",
      "code_information": [
        {
          "code": "3559390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER 4MM SB4000SA",
      "code_information": [
        {
          "code": "3559391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1162,
          "minimum": 244.02,
          "maximum": 850.8164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 782.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING 19F L",
      "code_information": [
        {
          "code": "3559394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCESS 8MM",
      "code_information": [
        {
          "code": "3559395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 939,
          "minimum": 197.19,
          "maximum": 687.5358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 632.5329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3559401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1438,
          "minimum": 301.98,
          "maximum": 1052.9036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 968.6713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FIBERLASE CO2",
      "code_information": [
        {
          "code": "3559407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3419.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0/PC-3  1865G",
      "code_information": [
        {
          "code": "3559425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MIC J FEDDING 8200",
      "code_information": [
        {
          "code": "3559430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 932.2956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT SINGLE 5' RT219",
      "code_information": [
        {
          "code": "3559433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 377,
          "minimum": 79.17,
          "maximum": 276.0394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 253.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT DUAL HTDRT380",
      "code_information": [
        {
          "code": "3559434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 386,
          "minimum": 81.06,
          "maximum": 282.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 260.0189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 EPM8706",
      "code_information": [
        {
          "code": "3559435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 814,
          "minimum": 170.94,
          "maximum": 596.0108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 548.3299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT OPEN EB240",
      "code_information": [
        {
          "code": "3559437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1537.21,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 2X315MM 703561",
      "code_information": [
        {
          "code": "3559445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.4648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VIZISNOT2 19G",
      "code_information": [
        {
          "code": "3559447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2067,
          "minimum": 434.07,
          "maximum": 1513.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1392.3808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIP 8.5X110 72200436",
      "code_information": [
        {
          "code": "3559448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X56MM 03.130.202",
      "code_information": [
        {
          "code": "3559456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.100",
      "code_information": [
        {
          "code": "3559462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 K-WIRE",
      "code_information": [
        {
          "code": "3559463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.5823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 22X10MM 03.501.760",
      "code_information": [
        {
          "code": "3559485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2487,
          "minimum": 522.27,
          "maximum": 1820.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1675.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2590S",
      "code_information": [
        {
          "code": "3559495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 191.3092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2591S",
      "code_information": [
        {
          "code": "3559496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 191.3092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM GPS 6143.2580S",
      "code_information": [
        {
          "code": "3559499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1243.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM GPS 6143.2582S",
      "code_information": [
        {
          "code": "3559500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1243.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM GPS 6143.2584S",
      "code_information": [
        {
          "code": "3559501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1243.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 8FR G00980",
      "code_information": [
        {
          "code": "3559527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-6MM BALT 110135",
      "code_information": [
        {
          "code": "3559542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 710,
          "minimum": 149.1,
          "maximum": 519.862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 116239",
      "code_information": [
        {
          "code": "3559543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1039,
          "minimum": 218.19,
          "maximum": 760.7558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 699.8953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-OVASSAPIAN 85MM BD6075",
      "code_information": [
        {
          "code": "3559545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/55 STANDARD 7607",
      "code_information": [
        {
          "code": "3559546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2974,
          "minimum": 624.54,
          "maximum": 2177.5628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2003.3578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8340050",
      "code_information": [
        {
          "code": "3559560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9498,
          "minimum": 1994.58,
          "maximum": 6954.4356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6398.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y3/8X3/16X3/16 10518",
      "code_information": [
        {
          "code": "3559582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CABLE 323.1090",
      "code_information": [
        {
          "code": "3559590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1886,
          "minimum": 396.06,
          "maximum": 1380.9292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1270.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BRAD POINT 4MM 323.010",
      "code_information": [
        {
          "code": "3559591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2034,
          "minimum": 427.14,
          "maximum": 1489.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1370.1512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRIPLE LUMEN 5.5FR",
      "code_information": [
        {
          "code": "3559593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1240,
          "minimum": 260.4,
          "maximum": 907.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 835.2938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL LUMEN 4FR",
      "code_information": [
        {
          "code": "3559594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1190,
          "minimum": 249.9,
          "maximum": 871.318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.6126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 4.5X15 9009-2001",
      "code_information": [
        {
          "code": "3559598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3360,
          "minimum": 705.6,
          "maximum": 2460.192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2263.3766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM XT SIGTRSB45AXT",
      "code_information": [
        {
          "code": "3559607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2514,
          "minimum": 527.94,
          "maximum": 1840.7508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1693.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/F P01-900-1902",
      "code_information": [
        {
          "code": "3559612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1822.1529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/M P01-900-1903",
      "code_information": [
        {
          "code": "3559613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1822.1529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEE-UTILIZATION PER CASE",
      "code_information": [
        {
          "code": "3559626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4344,
          "minimum": 912.24,
          "maximum": 3180.6768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2926.2227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV",
      "code_information": [
        {
          "code": "3559628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.8349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.0MM 705360",
      "code_information": [
        {
          "code": "3559634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1250,
          "minimum": 262.5,
          "maximum": 915.25,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 842.03,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SENSOR SPO2 1822A-25",
      "code_information": [
        {
          "code": "3559649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.8975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASO 12FR",
      "code_information": [
        {
          "code": "3559651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A435",
      "code_information": [
        {
          "code": "3559659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 264.7342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWRIST 2.5MM 60-25326",
      "code_information": [
        {
          "code": "3559663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 749.0699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #4 051114-10",
      "code_information": [
        {
          "code": "3559671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 163.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC",
      "code_information": [
        {
          "code": "3559672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 341,
          "minimum": 71.61,
          "maximum": 249.6802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 229.7058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 3.5X65",
      "code_information": [
        {
          "code": "3559673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1828,
          "minimum": 383.88,
          "maximum": 1338.4616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1231.3847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURETTE-0* TIP TDC005",
      "code_information": [
        {
          "code": "3559688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1469.1739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-0* TIP NAVIGATION",
      "code_information": [
        {
          "code": "3559690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1333.7755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON SILK    C-021-",
      "code_information": [
        {
          "code": "3560079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PS-2/4-0   J496G",
      "code_information": [
        {
          "code": "3560474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J492G",
      "code_information": [
        {
          "code": "3560778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J493G",
      "code_information": [
        {
          "code": "3560802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J494G",
      "code_information": [
        {
          "code": "3560836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 4-0  J-496-H",
      "code_information": [
        {
          "code": "3560879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.7438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-497-G",
      "code_information": [
        {
          "code": "3560893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-774-D",
      "code_information": [
        {
          "code": "3561255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.8633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J762D",
      "code_information": [
        {
          "code": "3561415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.6831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0        699H",
      "code_information": [
        {
          "code": "3561696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y496G",
      "code_information": [
        {
          "code": "3562112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y494G",
      "code_information": [
        {
          "code": "3562131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS-2    1666",
      "code_information": [
        {
          "code": "3562141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 40,
          "minimum": 8.4,
          "maximum": 29.288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 26.945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8619G",
      "code_information": [
        {
          "code": "3562217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8699G",
      "code_information": [
        {
          "code": "3562235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIVERSAL*****",
      "code_information": [
        {
          "code": "3566070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.2239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-EAR DAVOL 3 OZ 529****",
      "code_information": [
        {
          "code": "3566353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 35.0284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CT FAST LOAD DUAL",
      "code_information": [
        {
          "code": "3566355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-PACK DUAL EMPOWERCTA",
      "code_information": [
        {
          "code": "3566380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CRANIAL ACCESS  INSHITH",
      "code_information": [
        {
          "code": "3566755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2554,
          "minimum": 536.34,
          "maximum": 1870.0388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1720.4357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MULTI PODUS 9274-56XX",
      "code_information": [
        {
          "code": "3566785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 982,
          "minimum": 206.22,
          "maximum": 719.0204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 661.4988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NURSING SUPPLEMENTAL",
      "code_information": [
        {
          "code": "3566790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FECAL MANAGEMENT",
      "code_information": [
        {
          "code": "3566823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1240,
          "minimum": 260.4,
          "maximum": 907.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 835.2938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-REPLACEMENT FECAL MGMT",
      "code_information": [
        {
          "code": "3566824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3567605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 921,
          "minimum": 193.41,
          "maximum": 674.3562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 620.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "THERMOSET-INJECTATE    4142403",
      "code_information": [
        {
          "code": "3568123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 8.0MM",
      "code_information": [
        {
          "code": "3568561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.7627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 6.0MM",
      "code_information": [
        {
          "code": "3568562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 450,
          "minimum": 94.5,
          "maximum": 329.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.1308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3568563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.7627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 508,
          "minimum": 106.68,
          "maximum": 371.9576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU UNCUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4259105",
      "code_information": [
        {
          "code": "3568757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 380,
          "minimum": 79.8,
          "maximum": 278.236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.9771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-NEONATAL   42634-05",
      "code_information": [
        {
          "code": "3568760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXISENSOR-PEDIATRIC D20",
      "code_information": [
        {
          "code": "3568762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 147.5237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565200",
      "code_information": [
        {
          "code": "3569240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 763.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565150",
      "code_information": [
        {
          "code": "3569242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 763.216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16 FR",
      "code_information": [
        {
          "code": "3569250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 366,
          "minimum": 76.86,
          "maximum": 267.9852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 246.5464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18 FR",
      "code_information": [
        {
          "code": "3569252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 366,
          "minimum": 76.86,
          "maximum": 267.9852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 246.5464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH URETHRAL BARD 772415",
      "code_information": [
        {
          "code": "3569258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20,
          "minimum": 4.2,
          "maximum": 14.644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 13.4725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-ESOPH TRACH     5-18541",
      "code_information": [
        {
          "code": "3569601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1095,
          "minimum": 229.95,
          "maximum": 801.759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 737.6183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY CATH/DRN BAG 6176LL",
      "code_information": [
        {
          "code": "3569779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR   6146LL",
      "code_information": [
        {
          "code": "3569805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/ BAG 18FR  6148LL",
      "code_information": [
        {
          "code": "3569853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.0778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG LTX 16F 6165L",
      "code_information": [
        {
          "code": "3569870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LOOP CCL DYNJ50892",
      "code_information": [
        {
          "code": "3570230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 204.7817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMBAR PUNCTURE ADT 4301C",
      "code_information": [
        {
          "code": "3570322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMB PUNC PED   4304C****",
      "code_information": [
        {
          "code": "3570330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PARA/PUD PHARMASEAL 4540A",
      "code_information": [
        {
          "code": "3570603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 6.0F",
      "code_information": [
        {
          "code": "3570605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.7625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 8.3F",
      "code_information": [
        {
          "code": "3570610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1211,
          "minimum": 254.31,
          "maximum": 886.6942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 815.7587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SINGLE TAP BLOCK SPEC015",
      "code_information": [
        {
          "code": "3570640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 687,
          "minimum": 144.27,
          "maximum": 503.0214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 462.7797,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-NICU UMBILICAL CATH",
      "code_information": [
        {
          "code": "3570745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 543,
          "minimum": 114.03,
          "maximum": 397.5846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 365.7778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-DRESSING CHANGE 4D",
      "code_information": [
        {
          "code": "3571200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.9468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-THORACENTESIS CURITY 5014*",
      "code_information": [
        {
          "code": "3571304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 16FR 0100-16LV",
      "code_information": [
        {
          "code": "3571985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 254.6299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING W/ST 10F 43\\\"",
      "code_information": [
        {
          "code": "3571990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.4326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 8.0     86552",
      "code_information": [
        {
          "code": "3572176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.5597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 6LPC",
      "code_information": [
        {
          "code": "3572189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 743,
          "minimum": 156.03,
          "maximum": 544.0246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 500.5026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 6CFS",
      "code_information": [
        {
          "code": "3572191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 6MM",
      "code_information": [
        {
          "code": "3572195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 507,
          "minimum": 106.47,
          "maximum": 371.2254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 341.5274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRP MIC-KEY 14FR 1.5CM",
      "code_information": [
        {
          "code": "3572305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 678.3394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 35FR     125135",
      "code_information": [
        {
          "code": "3572307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 467.4951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 39FR     125139",
      "code_information": [
        {
          "code": "3572309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 467.4951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 41FR     125141",
      "code_information": [
        {
          "code": "3572311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 467.4951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 37FR LFT 125037",
      "code_information": [
        {
          "code": "3572315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 619,
          "minimum": 129.99,
          "maximum": 453.2318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 416.9733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BLAKEMORE 20 FR      9210",
      "code_information": [
        {
          "code": "3572344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2672,
          "minimum": 561.12,
          "maximum": 1956.4384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1799.9233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 5F 20\\\"     461412",
      "code_information": [
        {
          "code": "3572425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 6.5F 36\\\"   461438",
      "code_information": [
        {
          "code": "3572430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASOGASTRIC 8FR",
      "code_information": [
        {
          "code": "3572485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 18FR 20CC",
      "code_information": [
        {
          "code": "3572530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 237,
          "minimum": 49.77,
          "maximum": 173.5314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.6489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.5       86215",
      "code_information": [
        {
          "code": "3572860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.0       8621",
      "code_information": [
        {
          "code": "3572863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.0       86212",
      "code_information": [
        {
          "code": "3572865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.5       86213",
      "code_information": [
        {
          "code": "3572866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 8.0C      86216",
      "code_information": [
        {
          "code": "3572867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "3573037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "3573039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM",
      "code_information": [
        {
          "code": "3573355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 476.2522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 8MM",
      "code_information": [
        {
          "code": "3573357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 476.2522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF    SZs  DCTs",
      "code_information": [
        {
          "code": "3573530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 461,
          "minimum": 96.81,
          "maximum": 337.5442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 310.5407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FENESTRATED SZ 4TO10  CFN",
      "code_information": [
        {
          "code": "3573565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH #6   518035",
      "code_information": [
        {
          "code": "3573650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1965.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 8FR     8LPC",
      "code_information": [
        {
          "code": "3573714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 743,
          "minimum": 156.03,
          "maximum": 544.0246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 500.5026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,TRAC REINFO 6.0 86548",
      "code_information": [
        {
          "code": "3573730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.5597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 7.0     86550",
      "code_information": [
        {
          "code": "3573735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.5597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEEY PED",
      "code_information": [
        {
          "code": "3573845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 427,
          "minimum": 89.67,
          "maximum": 312.6494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.6374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 583,
          "minimum": 122.43,
          "maximum": 426.8726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 392.7228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 520,
          "minimum": 109.2,
          "maximum": 380.744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 350.2845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 0.8MM",
      "code_information": [
        {
          "code": "3573906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 337.4856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3573910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 435,
          "minimum": 91.35,
          "maximum": 318.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 293.0264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF BLU 10.0MM",
      "code_information": [
        {
          "code": "3573911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 6.0MM",
      "code_information": [
        {
          "code": "3573914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 6.0MM",
      "code_information": [
        {
          "code": "3573915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1400,
          "minimum": 294,
          "maximum": 1025.08,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 943.0736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 8.0MM",
      "code_information": [
        {
          "code": "3573916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF 7.0MM",
      "code_information": [
        {
          "code": "3573920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 278.2067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 60A160",
      "code_information": [
        {
          "code": "3573926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 672,
          "minimum": 141.12,
          "maximum": 492.0384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 452.6753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 7MM",
      "code_information": [
        {
          "code": "3573937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE XL 7",
      "code_information": [
        {
          "code": "3573950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNDERPAD-CGLIDE XL 40X80 PK",
      "code_information": [
        {
          "code": "3574527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-D&C COLLECTION 23116",
      "code_information": [
        {
          "code": "3574563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-MITY-ONE MYSTIC   10058",
      "code_information": [
        {
          "code": "3574642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 661,
          "minimum": 138.81,
          "maximum": 483.9842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 445.2655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI-REFLUX",
      "code_information": [
        {
          "code": "3574651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING TRACH    PMV007",
      "code_information": [
        {
          "code": "3574654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 879,
          "minimum": 184.59,
          "maximum": 643.6038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 592.1155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAX-BONE                  W31G",
      "code_information": [
        {
          "code": "3575105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.5844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER PK",
      "code_information": [
        {
          "code": "3575110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER XLPK",
      "code_information": [
        {
          "code": "3575115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 414,
          "minimum": 86.94,
          "maximum": 303.1308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 278.8803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-FOAM POSITIONING DISP",
      "code_information": [
        {
          "code": "3575122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MEDTRONIC ATRIAL    6492F",
      "code_information": [
        {
          "code": "3575572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.2542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK L/XL",
      "code_information": [
        {
          "code": "3575890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-THROMBIDISC TOPICAL HEMO",
      "code_information": [
        {
          "code": "3575891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 173.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD S/M",
      "code_information": [
        {
          "code": "3575892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD L/XL",
      "code_information": [
        {
          "code": "3575893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 518,
          "minimum": 108.78,
          "maximum": 379.2796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 348.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-LEG POSITIONER 111618",
      "code_information": [
        {
          "code": "3575894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK S/M",
      "code_information": [
        {
          "code": "3575895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRISTLET-PORTHOLE 6600021150",
      "code_information": [
        {
          "code": "3576870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH 442-2",
      "code_information": [
        {
          "code": "3576880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EXUDE HYDRO 6X6",
      "code_information": [
        {
          "code": "3580000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-OPTICELL AG+4X5",
      "code_information": [
        {
          "code": "3580001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.2865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 16FR",
      "code_information": [
        {
          "code": "3580005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST RT XS 8",
      "code_information": [
        {
          "code": "3580008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.7172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LT XS 8",
      "code_information": [
        {
          "code": "3580009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.8766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 EASY CAP II",
      "code_information": [
        {
          "code": "3580015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 171,
          "minimum": 35.91,
          "maximum": 125.2062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 14FR",
      "code_information": [
        {
          "code": "3580016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-NASAL L/R STANDARD",
      "code_information": [
        {
          "code": "3580017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 262,
          "minimum": 55.02,
          "maximum": 191.8364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 176.4895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT MED CLOSED",
      "code_information": [
        {
          "code": "3580023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.2239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,OVAL 5.5X13CM AR-8550COE",
      "code_information": [
        {
          "code": "3580025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 305.8253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3590000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1467,
          "minimum": 308.07,
          "maximum": 1074.1374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 988.2064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTROSTOMY 18FR   100-18",
      "code_information": [
        {
          "code": "3590008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 254.6299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY BASIC         4380",
      "code_information": [
        {
          "code": "3590013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 301,
          "minimum": 63.21,
          "maximum": 220.3922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 202.7608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSAL 10FR  15642-001",
      "code_information": [
        {
          "code": "3590100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REPAIR ASH CATH      RPK01",
      "code_information": [
        {
          "code": "3590134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 693,
          "minimum": 145.53,
          "maximum": 507.4146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 466.8214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LMH LMH-1001",
      "code_information": [
        {
          "code": "3598009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1808.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 03.130.302",
      "code_information": [
        {
          "code": "3598013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-BLUE RHINO G2",
      "code_information": [
        {
          "code": "3598017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1921.8493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-STERLING 3.0X60X150",
      "code_information": [
        {
          "code": "3598023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1841,
          "minimum": 386.61,
          "maximum": 1347.9802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1240.1418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORGANIZER-7 DAY PILL 70069L",
      "code_information": [
        {
          "code": "3598024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I-KNIFE II 8065921502",
      "code_information": [
        {
          "code": "3598025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 95.6546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARDS-NEONATAL NOISE NON-MAG",
      "code_information": [
        {
          "code": "3598028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 215,
          "minimum": 45.15,
          "maximum": 157.423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE RCM-14815",
      "code_information": [
        {
          "code": "3598048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 839,
          "minimum": 176.19,
          "maximum": 614.3158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 565.1705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPEN KNEE ABS-2001-OT",
      "code_information": [
        {
          "code": "3598069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3230.0271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE GEL",
      "code_information": [
        {
          "code": "3598076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 168.406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACEMENT GEL",
      "code_information": [
        {
          "code": "3598077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER GEL",
      "code_information": [
        {
          "code": "3598078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 168.406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-SAMPLE EXTENSION 1841-25",
      "code_information": [
        {
          "code": "3598081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.2106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-8MM ENT TUBE NVM5 2010480",
      "code_information": [
        {
          "code": "3598086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.9253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-MEGADYNE 10FT SMOKE",
      "code_information": [
        {
          "code": "3598109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 156.9544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MEGADYNE F/SMOKE",
      "code_information": [
        {
          "code": "3598110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ZIP PEN F/SMOKE EVAC",
      "code_information": [
        {
          "code": "3598111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 238.4629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER SO SPECTRUM SU",
      "code_information": [
        {
          "code": "3598112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 376.5558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER S1 SPECTRUM SU",
      "code_information": [
        {
          "code": "3598113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 376.5558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1603G",
      "code_information": [
        {
          "code": "3598114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 1661G",
      "code_information": [
        {
          "code": "3598115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MINIVAC MGVSFT10",
      "code_information": [
        {
          "code": "3598117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.9601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHTMAT-ULTRATHIN UA2550",
      "code_information": [
        {
          "code": "3598118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 818,
          "minimum": 171.78,
          "maximum": 598.9396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 551.0244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MEGADYN SPECULUM 23951",
      "code_information": [
        {
          "code": "3598134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-221C-0427",
      "code_information": [
        {
          "code": "3598154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 536.2047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLIDE-OCULAR KDB GLIDE",
      "code_information": [
        {
          "code": "3598156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROVU DISP PHB-03",
      "code_information": [
        {
          "code": "3598158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11119,
          "minimum": 2334.99,
          "maximum": 8141.3318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7490.0253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BLUGRIGGS PERC DILATION",
      "code_information": [
        {
          "code": "3598159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2213,
          "minimum": 464.73,
          "maximum": 1620.3586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1490.7299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5X10 AR-8610TDC-01C",
      "code_information": [
        {
          "code": "3598172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1582.3428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-EGG 4.0MM 5820-015-040",
      "code_information": [
        {
          "code": "3598178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 2.0 6007-1200",
      "code_information": [
        {
          "code": "3598184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.0889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY SZ 8 8DCFS",
      "code_information": [
        {
          "code": "3598187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBT 7MM EMG ET 2010470",
      "code_information": [
        {
          "code": "3598201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.9253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LAPIPLASTY 40X11 SM-4011",
      "code_information": [
        {
          "code": "3598213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-MULTIPURPOSE TUBING",
      "code_information": [
        {
          "code": "3598219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.0303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-REINFUSION SB1E",
      "code_information": [
        {
          "code": "3598227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 3.2 HAMMER 702632",
      "code_information": [
        {
          "code": "3598233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4242,
          "minimum": 890.82,
          "maximum": 3105.9924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2857.513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK DS AR-8991DS",
      "code_information": [
        {
          "code": "3598238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 406.98,
          "maximum": 1419.0036,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1305.4833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 PLUS VCP317H",
      "code_information": [
        {
          "code": "3598242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.7362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM CSS-072-37-SQ",
      "code_information": [
        {
          "code": "3598257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 977.4284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-Z-FLO FLUID",
      "code_information": [
        {
          "code": "3598273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 441,
          "minimum": 92.61,
          "maximum": 322.9002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.0682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-25 G00896",
      "code_information": [
        {
          "code": "3598279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 193,
          "minimum": 40.53,
          "maximum": 141.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.0094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HIGH TORQUE 70-2001",
      "code_information": [
        {
          "code": "3598282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1378,
          "minimum": 289.38,
          "maximum": 1008.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 928.2539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP523H",
      "code_information": [
        {
          "code": "3598283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.4592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.3MM AR-7535",
      "code_information": [
        {
          "code": "3598289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 503.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYNGECTOMY SZ10 6132",
      "code_information": [
        {
          "code": "3598291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2343,
          "minimum": 492.03,
          "maximum": 1715.5446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1578.301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUNCTURE 17FR/10MM 8141US",
      "code_information": [
        {
          "code": "3598296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2695,
          "minimum": 565.95,
          "maximum": 1973.279,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1815.4167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORCAPOD SUCTION BIOPSY",
      "code_information": [
        {
          "code": "3598300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 108.4535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-E-Z CLEAN 0016AM",
      "code_information": [
        {
          "code": "3598301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 22GX.75\\\"",
      "code_information": [
        {
          "code": "3598320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL 80M 04.038.380S",
      "code_information": [
        {
          "code": "3598333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4478,
          "minimum": 940.38,
          "maximum": 3278.7916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3016.4883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153204",
      "code_information": [
        {
          "code": "3598338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 SURGILON 8886195151",
      "code_information": [
        {
          "code": "3598362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.7438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 SURGILON 8886195141",
      "code_information": [
        {
          "code": "3598363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUB LIPO 3-TT-FILTRON",
      "code_information": [
        {
          "code": "3598384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2403,
          "minimum": 504.63,
          "maximum": 1759.4766,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1618.7185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHEST-DRAIN 4050-100N",
      "code_information": [
        {
          "code": "3598393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 321.3186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEO TEE 1050810",
      "code_information": [
        {
          "code": "3598397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 194.0037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION SZ:8",
      "code_information": [
        {
          "code": "3598398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 10.5 CLR",
      "code_information": [
        {
          "code": "3598403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY L-WIRE 20115",
      "code_information": [
        {
          "code": "3598404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 362,
          "minimum": 76.02,
          "maximum": 265.0564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-LIGATING SURGITIE SGL-1",
      "code_information": [
        {
          "code": "3598405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 621,
          "minimum": 130.41,
          "maximum": 454.6962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 418.3205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 11 96\\\" Z880G",
      "code_information": [
        {
          "code": "3598407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-POWER 45MM FLEX PSEE45",
      "code_information": [
        {
          "code": "3598408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2062,
          "minimum": 433.02,
          "maximum": 1509.7964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1389.0127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 32FR 056132",
      "code_information": [
        {
          "code": "3598409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SOFSIK 2-0 18\\\" GS63M",
      "code_information": [
        {
          "code": "3598410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 153.5863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOSOF 5-0 SN-661",
      "code_information": [
        {
          "code": "3598412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1 G48",
      "code_information": [
        {
          "code": "3598413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0 3844G",
      "code_information": [
        {
          "code": "3598415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.9601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 714G",
      "code_information": [
        {
          "code": "3598417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD WARMING RAPID 24355",
      "code_information": [
        {
          "code": "3598418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTOLOGY 2.3MMX240CM",
      "code_information": [
        {
          "code": "3598419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 163.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY LONG 2.4MM E1450-6",
      "code_information": [
        {
          "code": "3598420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y527H",
      "code_information": [
        {
          "code": "3598424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-GRAVITY SPIKE FLUID MGMT",
      "code_information": [
        {
          "code": "3598425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEM SILVER 6.5X7",
      "code_information": [
        {
          "code": "3598426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 154.2599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 20FR 5CC",
      "code_information": [
        {
          "code": "3598427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-J-TIP .035X145CM",
      "code_information": [
        {
          "code": "3598428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 222.2959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 30CC 16FR",
      "code_information": [
        {
          "code": "3598429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.3491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2 490T",
      "code_information": [
        {
          "code": "3598434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII BLADED CTB33",
      "code_information": [
        {
          "code": "3598436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM BLADELESS CTR03",
      "code_information": [
        {
          "code": "3598437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND 10FR DYNJWE1321A",
      "code_information": [
        {
          "code": "3598439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ULNAR NERVE 79-91100",
      "code_information": [
        {
          "code": "3598441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POWDER-HEMOSTAT AVITENE 1 GRAM",
      "code_information": [
        {
          "code": "3598442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1703,
          "minimum": 357.63,
          "maximum": 1246.9366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1147.1817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RADIAL ARTERY 20GX1.75\\\"",
      "code_information": [
        {
          "code": "3598444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 265,
          "minimum": 55.65,
          "maximum": 194.033,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.5104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL RHINO ROCKET LRG",
      "code_information": [
        {
          "code": "3598446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-FOREIGN BODY 60613",
      "code_information": [
        {
          "code": "3598447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 663,
          "minimum": 139.23,
          "maximum": 485.4486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 446.6127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 24FR 056124",
      "code_information": [
        {
          "code": "3598448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-HYDROFERA 6X6 HB6614",
      "code_information": [
        {
          "code": "3598449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.85,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SMALL WIDE",
      "code_information": [
        {
          "code": "3598450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 147.5237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARYNGECTOMY SZ6 6LGT",
      "code_information": [
        {
          "code": "3598451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 457,
          "minimum": 95.97,
          "maximum": 334.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 307.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X285MM 703586",
      "code_information": [
        {
          "code": "3598458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.2712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.2712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 18FR",
      "code_information": [
        {
          "code": "3598463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 660.1515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATFORM-GELPOINT PATH CNB11",
      "code_information": [
        {
          "code": "3598471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3325.0081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VINYL CONNECTING G02791",
      "code_information": [
        {
          "code": "3598473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 155.6071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRUIT, CROSS VENT 80011",
      "code_information": [
        {
          "code": "3598474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 323,
          "minimum": 67.83,
          "maximum": 236.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 217.5806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR, NEO W/MASK",
      "code_information": [
        {
          "code": "3598475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 342,
          "minimum": 71.82,
          "maximum": 250.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 230.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3598478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 524.7531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC #1 48G",
      "code_information": [
        {
          "code": "3598479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.2239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STEM 222-496100",
      "code_information": [
        {
          "code": "3598480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5912,
          "minimum": 1241.52,
          "maximum": 4328.7664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3982.4651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRIP-PLATINUM MS04R-IP10X-0JH",
      "code_information": [
        {
          "code": "3598481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4118,
          "minimum": 864.78,
          "maximum": 3015.1996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2773.9836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-ENDOCAPSULE 10 MAJ2027",
      "code_information": [
        {
          "code": "3598483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3003,
          "minimum": 630.63,
          "maximum": 2198.7966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2022.8929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-10G/7.75\\\" 0306-810-000",
      "code_information": [
        {
          "code": "3598484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 724,
          "minimum": 152.04,
          "maximum": 530.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 487.7038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77420",
      "code_information": [
        {
          "code": "3598485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 584,
          "minimum": 122.64,
          "maximum": 427.6048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 393.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/SUPPORT #6",
      "code_information": [
        {
          "code": "3598487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 784,
          "minimum": 164.64,
          "maximum": 574.0448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 528.1212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST 4050-100N",
      "code_information": [
        {
          "code": "3598488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 475.5785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-GONIOTOMY TRABEX 600042",
      "code_information": [
        {
          "code": "3598489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3014,
          "minimum": 632.94,
          "maximum": 2206.8508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2030.3027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-STRAIGHT JAW NSLX137S",
      "code_information": [
        {
          "code": "3598493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2542,
          "minimum": 533.82,
          "maximum": 1861.2524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1712.3522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW NSLX137C",
      "code_information": [
        {
          "code": "3598494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2637,
          "minimum": 553.77,
          "maximum": 1930.8114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1776.3465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW 25CM NSLX125C",
      "code_information": [
        {
          "code": "3598495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2676,
          "minimum": 561.96,
          "maximum": 1959.3672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1802.6178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JADA POSTPARTUM",
      "code_information": [
        {
          "code": "3598497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5844,
          "minimum": 1227.24,
          "maximum": 4278.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3936.6587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA G PROCEDURAL PUG",
      "code_information": [
        {
          "code": "3598498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9014,
          "minimum": 1892.94,
          "maximum": 6600.0508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6072.0467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-4MM/SHORT 1149.8052",
      "code_information": [
        {
          "code": "3598502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1718.4148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN",
      "code_information": [
        {
          "code": "3598508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN",
      "code_information": [
        {
          "code": "3598509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1055,
          "minimum": 221.55,
          "maximum": 772.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 710.6733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94975",
      "code_information": [
        {
          "code": "3598515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1030,
          "minimum": 216.3,
          "maximum": 754.166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 693.8327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYN W/EL SZ10 6136",
      "code_information": [
        {
          "code": "3598520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4004,
          "minimum": 840.84,
          "maximum": 2931.7288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2697.1905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.4X100/LG AGK10100",
      "code_information": [
        {
          "code": "3598521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X120MM 45302001",
      "code_information": [
        {
          "code": "3598524",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 265.4079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNIT-TI-KNOT QUICK LOAD 030510",
      "code_information": [
        {
          "code": "3598527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PICO 14 WOUND 15X30CM",
      "code_information": [
        {
          "code": "3598530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1724,
          "minimum": 362.04,
          "maximum": 1262.3128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1161.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1590,
          "minimum": 333.9,
          "maximum": 1164.198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1071.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY STANDARD 7607",
      "code_information": [
        {
          "code": "3598534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1347,
          "minimum": 282.87,
          "maximum": 986.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 907.3715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND XTRASORB 6X9",
      "code_information": [
        {
          "code": "3598535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1828,
          "minimum": 383.88,
          "maximum": 1338.4616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1231.3847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS SELECT",
      "code_information": [
        {
          "code": "3598538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY",
      "code_information": [
        {
          "code": "3598539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1496,
          "minimum": 314.16,
          "maximum": 1095.3712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1007.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LK/MD 3.1X328 705077",
      "code_information": [
        {
          "code": "3598547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1526,
          "minimum": 320.46,
          "maximum": 1117.3372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1027.9502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E-CATH PLUS 251285-41E",
      "code_information": [
        {
          "code": "3598551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-OVAL CUP BIOPSY SINGLE",
      "code_information": [
        {
          "code": "3598561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 394.07,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEATED W/GAS FILTER",
      "code_information": [
        {
          "code": "3598562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 652,
          "minimum": 136.92,
          "maximum": 477.3944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 439.2028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-10X360/RT/130* 3430-0360S",
      "code_information": [
        {
          "code": "3598565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6277,
          "minimum": 1318.17,
          "maximum": 4596.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4228.3378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3598587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X65MM 03.130.201",
      "code_information": [
        {
          "code": "3598592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1114,
          "minimum": 233.94,
          "maximum": 815.6708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 750.4171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-AIRSEAL CANN 8MM IAS8-DV",
      "code_information": [
        {
          "code": "3598593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 756.4798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTERD FURCATED ASM-EVAC",
      "code_information": [
        {
          "code": "3598594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 756.4798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS + MAP152",
      "code_information": [
        {
          "code": "3598601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRIVE T6 VARIAX2 705132",
      "code_information": [
        {
          "code": "3598602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2210,
          "minimum": 464.1,
          "maximum": 1618.162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1488.709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREW T7 AO 45-27015",
      "code_information": [
        {
          "code": "3598609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1540,
          "minimum": 323.4,
          "maximum": 1127.588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1037.381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROXIMATE PROCEDURE PPH03",
      "code_information": [
        {
          "code": "3598617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2668,
          "minimum": 560.28,
          "maximum": 1953.5096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1797.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X7MM 60-16007",
      "code_information": [
        {
          "code": "3598624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1349,
          "minimum": 283.29,
          "maximum": 987.7378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 908.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.9X115/35MM 92-19135",
      "code_information": [
        {
          "code": "3598625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2047,
          "minimum": 429.87,
          "maximum": 1498.8134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1378.9083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 177.1631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-EDIPURAL 17GX3.5 BUPIV",
      "code_information": [
        {
          "code": "3598647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 362,
          "minimum": 76.02,
          "maximum": 265.0564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.8519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 0.3MM DWD055",
      "code_information": [
        {
          "code": "3598653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1389,
          "minimum": 291.69,
          "maximum": 1017.0258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 935.6637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #2",
      "code_information": [
        {
          "code": "3598662",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.7607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDICLE ACCESS 624.027S",
      "code_information": [
        {
          "code": "3598668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3040.0651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISTAL DUODENOVIDEOSCOPE",
      "code_information": [
        {
          "code": "3598674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3598678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 974,
          "minimum": 204.54,
          "maximum": 713.1628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 656.1098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 24FR 77424",
      "code_information": [
        {
          "code": "3598679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 486,
          "minimum": 102.06,
          "maximum": 355.8492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.3813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X13MM AR-300-B001",
      "code_information": [
        {
          "code": "3598688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2343,
          "minimum": 492.03,
          "maximum": 1715.5446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1578.301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X19.5MM AR-300-B201",
      "code_information": [
        {
          "code": "3598689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2396,
          "minimum": 503.16,
          "maximum": 1754.3512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1614.0031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8710H",
      "code_information": [
        {
          "code": "3598695",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 183.2257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8725H",
      "code_information": [
        {
          "code": "3598696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 385,
          "minimum": 80.85,
          "maximum": 281.897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.3452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8806H",
      "code_information": [
        {
          "code": "3598697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.5597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8718H",
      "code_information": [
        {
          "code": "3598698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 173.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8714H",
      "code_information": [
        {
          "code": "3598699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 215,
          "minimum": 45.15,
          "maximum": 157.423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W SPPRT MXPRSK05",
      "code_information": [
        {
          "code": "3598700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.7607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-BENSTON 260CM/.035\\\"",
      "code_information": [
        {
          "code": "3598702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.8083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/ SUPPORT #3",
      "code_information": [
        {
          "code": "3598704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.7607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-LT 130°/10X420 3530-0420S",
      "code_information": [
        {
          "code": "3598705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6277,
          "minimum": 1318.17,
          "maximum": 4596.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4228.3378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-XI 45MM 480445",
      "code_information": [
        {
          "code": "3598714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3242,
          "minimum": 680.82,
          "maximum": 2373.7924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2183.889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-MUSTANG 7.0X20X135CM",
      "code_information": [
        {
          "code": "3598729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.4759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT,ACTIVE ANKLE HEEL-LOCK",
      "code_information": [
        {
          "code": "3598758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 464,
          "minimum": 97.44,
          "maximum": 339.7408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 312.5615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Suture-7-0 Prolene Blue 8704H",
      "code_information": [
        {
          "code": "3598759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.5521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR,SURGICEL 3123SPEA",
      "code_information": [
        {
          "code": "3598761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.9069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP ESREC",
      "code_information": [
        {
          "code": "3598782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 3.0X2.1 45-30005",
      "code_information": [
        {
          "code": "3598799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1849,
          "minimum": 388.29,
          "maximum": 1353.8378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1245.5308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAC 425840405",
      "code_information": [
        {
          "code": "3598801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-8737-37",
      "code_information": [
        {
          "code": "3598812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE,.045\\\" THD AR-8737-05",
      "code_information": [
        {
          "code": "3598815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.74,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO 2.0MM DC6106",
      "code_information": [
        {
          "code": "3598843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1175.4739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.5X150MM 58862515",
      "code_information": [
        {
          "code": "3598844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM DSDS1011",
      "code_information": [
        {
          "code": "3598845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.5MM DSDS0025",
      "code_information": [
        {
          "code": "3598846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1283.9273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.0MM DSDS0030",
      "code_information": [
        {
          "code": "3598853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1283.9273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR SHEEHY 510-131C",
      "code_information": [
        {
          "code": "3598870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.0929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR PAPERELLA 510-043C",
      "code_information": [
        {
          "code": "3598871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.1973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F X-FIT 60-80323",
      "code_information": [
        {
          "code": "3598874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 977.4284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F 1.7MM 60-80317",
      "code_information": [
        {
          "code": "3598875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 977.4284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EAR-SPEEDIWICK 15MM OT-5201-50",
      "code_information": [
        {
          "code": "3598882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 15CM APYX-15-TP",
      "code_information": [
        {
          "code": "3598955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3007,
          "minimum": 631.47,
          "maximum": 2201.7254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2025.5874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERIOTOMY",
      "code_information": [
        {
          "code": "3598957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 594.81,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/46-62\\\" 1143PP",
      "code_information": [
        {
          "code": "3598975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 6.0 BIPOLAR",
      "code_information": [
        {
          "code": "3598997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2604,
          "minimum": 546.84,
          "maximum": 1906.6488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1754.1169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 004025",
      "code_information": [
        {
          "code": "3599029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.8766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-WIGGLE OPTIFLOW JR 2 M",
      "code_information": [
        {
          "code": "3599030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND HANZ RT LG",
      "code_information": [
        {
          "code": "3599041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 494,
          "minimum": 103.74,
          "maximum": 361.7068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 332.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.65MM MD 45303065",
      "code_information": [
        {
          "code": "3599049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.55MM MD 45303055",
      "code_information": [
        {
          "code": "3599050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8305H",
      "code_information": [
        {
          "code": "3599073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-S-CURVE URETH DIL G32789",
      "code_information": [
        {
          "code": "3599074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2036,
          "minimum": 427.56,
          "maximum": 1490.7592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1371.4985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5x57MM 03.130.211",
      "code_information": [
        {
          "code": "3599095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
      "code_information": [
        {
          "code": "3599096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3781.0515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002352",
      "code_information": [
        {
          "code": "3599098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2262,
          "minimum": 475.02,
          "maximum": 1656.2364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1523.7375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002351",
      "code_information": [
        {
          "code": "3599099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2262,
          "minimum": 475.02,
          "maximum": 1656.2364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1523.7375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-BEADED 3MM 4150004030",
      "code_information": [
        {
          "code": "3599100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1311.5459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LONG ENCOMPASS JAW OLH",
      "code_information": [
        {
          "code": "3599110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 22744,
          "minimum": 4776.24,
          "maximum": 16653.1568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 15320.9043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
      "code_information": [
        {
          "code": "3599114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4881,
          "minimum": 1025.01,
          "maximum": 3573.8682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3287.9587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-270-330C ALLOX-FH12SE",
      "code_information": [
        {
          "code": "3599115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6475,
          "minimum": 1359.75,
          "maximum": 4740.995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4361.7154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.3MM CSS-040-23",
      "code_information": [
        {
          "code": "3599133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 221.6223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-NAIL 3MM 4150004025",
      "code_information": [
        {
          "code": "3599135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1311.5459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-FULL VIP1137430",
      "code_information": [
        {
          "code": "3599140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FILL VIP1137431",
      "code_information": [
        {
          "code": "3599141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 191.3092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #4",
      "code_information": [
        {
          "code": "3599144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 870,
          "minimum": 182.7,
          "maximum": 637.014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 586.0529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-HINGED KNEE LG 11-0672-4",
      "code_information": [
        {
          "code": "3599145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 872,
          "minimum": 183.12,
          "maximum": 638.4784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 587.4001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-PROCESSOR DEPTH Z179994",
      "code_information": [
        {
          "code": "3599155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2423,
          "minimum": 508.83,
          "maximum": 1774.1206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1632.191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X230/200MM 315.93",
      "code_information": [
        {
          "code": "3599157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1826,
          "minimum": 383.46,
          "maximum": 1336.9972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1230.0374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TENSIONER-CERCLAGE AR-7820",
      "code_information": [
        {
          "code": "3599172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2030,
          "minimum": 426.3,
          "maximum": 1486.366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1367.4567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CERCLAGE STR/LG AR-7822",
      "code_information": [
        {
          "code": "3599173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1118.8895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-INS MID/HINDFOOT FFSP1530",
      "code_information": [
        {
          "code": "3599178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1695.5116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LP PRP LEUKOCYTE POOR PRS6",
      "code_information": [
        {
          "code": "3599190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3723,
          "minimum": 781.83,
          "maximum": 2725.9806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2507.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-4160-40",
      "code_information": [
        {
          "code": "3599227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.0793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SET RENOVARP GIS-30",
      "code_information": [
        {
          "code": "3599230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/135X45 03.133.102",
      "code_information": [
        {
          "code": "3599237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1522,
          "minimum": 319.62,
          "maximum": 1114.4084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1025.2557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-100.783+/3H 954-0035",
      "code_information": [
        {
          "code": "3599249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1448,
          "minimum": 304.08,
          "maximum": 1060.2256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 975.4076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PARACENTESIS GIS-31",
      "code_information": [
        {
          "code": "3599291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 633.2066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MALE EXT PWM-030 PUREWICK",
      "code_information": [
        {
          "code": "3599292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.3225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 2 1/2\\\"",
      "code_information": [
        {
          "code": "3599298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 3\\\"",
      "code_information": [
        {
          "code": "3599299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-PLANTAR KERATOSIS WOMENS",
      "code_information": [
        {
          "code": "3599300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" SMALL",
      "code_information": [
        {
          "code": "3599306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" MEDIUM",
      "code_information": [
        {
          "code": "3599307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" LARGE",
      "code_information": [
        {
          "code": "3599308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE DOUBLE",
      "code_information": [
        {
          "code": "3599309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE SINGLE",
      "code_information": [
        {
          "code": "3599310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE LEFT",
      "code_information": [
        {
          "code": "3599311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE RIGHT",
      "code_information": [
        {
          "code": "3599312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 25GX5”",
      "code_information": [
        {
          "code": "3599313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 251,
          "minimum": 52.71,
          "maximum": 183.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.0796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3599314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1037,
          "minimum": 217.77,
          "maximum": 759.2914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 698.5481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXYGENATOR-PERFUSION 050715",
      "code_information": [
        {
          "code": "3599315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1812,
          "minimum": 380.52,
          "maximum": 1326.7464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1220.6067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-Y TYPE PERFUSION 10004",
      "code_information": [
        {
          "code": "3599362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.9525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 19G X 1.5\\\"CT",
      "code_information": [
        {
          "code": "3599369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.8558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM TUBING 8H23R12",
      "code_information": [
        {
          "code": "3599370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2383,
          "minimum": 500.43,
          "maximum": 1744.8326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1605.246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.7/125MM 03.133.105",
      "code_information": [
        {
          "code": "3599378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1325,
          "minimum": 278.25,
          "maximum": 970.165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 892.5518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-PIECE-OXYGEN MONITOR",
      "code_information": [
        {
          "code": "3599381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 5ML GIS-55",
      "code_information": [
        {
          "code": "3599412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-FINGER XL A8685",
      "code_information": [
        {
          "code": "3599413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.1973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY 040-300",
      "code_information": [
        {
          "code": "3599414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RET 5MM/155CM FB-231D.A",
      "code_information": [
        {
          "code": "3599417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/135X45 03.133.106",
      "code_information": [
        {
          "code": "3599424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1497,
          "minimum": 314.37,
          "maximum": 1096.1034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1008.4151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL N8 PROCESSOR DUALN8",
      "code_information": [
        {
          "code": "3599512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62546,
          "minimum": 13134.66,
          "maximum": 45796.1812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42132.4867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0 EPM8703",
      "code_information": [
        {
          "code": "3599513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 901,
          "minimum": 189.21,
          "maximum": 659.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 606.9352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.002",
      "code_information": [
        {
          "code": "3599527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 944,
          "minimum": 198.24,
          "maximum": 691.1968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 635.9011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOYSTICK-RED 5MM 03.211.454",
      "code_information": [
        {
          "code": "3599531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2911,
          "minimum": 611.31,
          "maximum": 2131.4342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1960.9195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IABC 40CC 7FR IMU7F-40",
      "code_information": [
        {
          "code": "3599539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5359,
          "minimum": 1125.39,
          "maximum": 3923.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3609.951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-SD 2MM T6 313.843.V",
      "code_information": [
        {
          "code": "3599548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1853,
          "minimum": 389.13,
          "maximum": 1356.7666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1248.2253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIX 1.1MM DC4212",
      "code_information": [
        {
          "code": "3599593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 794.8763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 70MM",
      "code_information": [
        {
          "code": "3599601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.3984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 100MM",
      "code_information": [
        {
          "code": "3599602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.3984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE SMALL",
      "code_information": [
        {
          "code": "3599607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.8633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE MEDIUM",
      "code_information": [
        {
          "code": "3599608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.8633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE LARGE",
      "code_information": [
        {
          "code": "3599609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.8633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE X-LARGE",
      "code_information": [
        {
          "code": "3599610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.8633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 3520",
      "code_information": [
        {
          "code": "3599611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4030",
      "code_information": [
        {
          "code": "3599612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4540",
      "code_information": [
        {
          "code": "3599613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5040",
      "code_information": [
        {
          "code": "3599614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5550",
      "code_information": [
        {
          "code": "3599615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.6337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 35-40CM",
      "code_information": [
        {
          "code": "3599617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 293,
          "minimum": 61.53,
          "maximum": 214.5346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 197.3718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 40-45CM",
      "code_information": [
        {
          "code": "3599618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 293,
          "minimum": 61.53,
          "maximum": 214.5346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 197.3718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE CVD AC-20055390",
      "code_information": [
        {
          "code": "3599638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1368,
          "minimum": 287.28,
          "maximum": 1001.6496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 921.5176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE STRAIGHT",
      "code_information": [
        {
          "code": "3599639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1369,
          "minimum": 287.49,
          "maximum": 1002.3818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 922.1913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .315\\\" NAR 200138107S",
      "code_information": [
        {
          "code": "3599664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .50\\\" WIDE 200138108S",
      "code_information": [
        {
          "code": "3599666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-BONE SCREW IB200051",
      "code_information": [
        {
          "code": "3599670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1584,
          "minimum": 332.64,
          "maximum": 1159.8048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1067.0204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDES-PT SPECIFIC PROPINF",
      "code_information": [
        {
          "code": "3599671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7311,
          "minimum": 1535.31,
          "maximum": 5353.1142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4924.8651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 2.4MM 200072",
      "code_information": [
        {
          "code": "3599672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.9031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CORNER 4.8MM 33600048",
      "code_information": [
        {
          "code": "3599673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2020,
          "minimum": 424.2,
          "maximum": 1479.044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1360.7205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACID-5% ACETIC 9045052",
      "code_information": [
        {
          "code": "3599696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL CARE DUOCARE MDS604DC",
      "code_information": [
        {
          "code": "3599708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.5996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3599751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.4592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-INTERSEPT 6031",
      "code_information": [
        {
          "code": "3599752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X1/4X1/4 Y 6036",
      "code_information": [
        {
          "code": "3599753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/2X3/8X3/8 6040",
      "code_information": [
        {
          "code": "3599754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.4592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PERFUSE 1/4\\\" 10007",
      "code_information": [
        {
          "code": "3599756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/M P01-900-1703",
      "code_information": [
        {
          "code": "3599770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1822.1529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH 82-1516",
      "code_information": [
        {
          "code": "3599774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1505,
          "minimum": 316.05,
          "maximum": 1101.961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1013.8041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOPRO-VASOVIEW 2 VEIN",
      "code_information": [
        {
          "code": "3599778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6789,
          "minimum": 1425.69,
          "maximum": 4970.9058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4573.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 5F 20\\\"",
      "code_information": [
        {
          "code": "3599779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 6.5F 36\\\"",
      "code_information": [
        {
          "code": "3599780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.2163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UNIVERSAL PALM MEDIUM",
      "code_information": [
        {
          "code": "3599787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 17GX4.5\\\"",
      "code_information": [
        {
          "code": "3599788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 155.6071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPACER IN-LINE 42-RTC24-VP",
      "code_information": [
        {
          "code": "3599789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRIMARY DUOVENT 1424828",
      "code_information": [
        {
          "code": "3599790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-PED ANES W/FILTER",
      "code_information": [
        {
          "code": "3599791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 143,
          "minimum": 30.03,
          "maximum": 104.7046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.3282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 45MM",
      "code_information": [
        {
          "code": "3599808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2874,
          "minimum": 603.54,
          "maximum": 2104.3428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1935.9954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 60MM",
      "code_information": [
        {
          "code": "3599809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3133,
          "minimum": 657.93,
          "maximum": 2293.9826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2110.464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 368,
          "minimum": 77.28,
          "maximum": 269.4496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 247.8936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 250.5881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ATERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.7741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 10CM SHORT",
      "code_information": [
        {
          "code": "3599881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.8349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 8CM SHORT",
      "code_information": [
        {
          "code": "3599882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-LP 2MMX4CM RBYLP0204",
      "code_information": [
        {
          "code": "3599885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4457,
          "minimum": 935.97,
          "maximum": 3263.4154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3002.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.1X70 KWIRE 03.130.200",
      "code_information": [
        {
          "code": "3599922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5X7 STD AR-7350TD",
      "code_information": [
        {
          "code": "3599951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 746.3754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY G 18FR 2.7",
      "code_information": [
        {
          "code": "3599960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 660.1515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING DISP FG-600U",
      "code_information": [
        {
          "code": "3600018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 782,
          "minimum": 164.22,
          "maximum": 572.5804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 526.774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT 10012",
      "code_information": [
        {
          "code": "3600074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/36 7413",
      "code_information": [
        {
          "code": "3600119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1452,
          "minimum": 304.92,
          "maximum": 1063.1544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 978.102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PROVOX XTRAFLOW HME",
      "code_information": [
        {
          "code": "3600120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 10/36",
      "code_information": [
        {
          "code": "3600121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 977.4284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORA/PARA 6FRTAPS-6F-12PT",
      "code_information": [
        {
          "code": "3600163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 835,
          "minimum": 175.35,
          "maximum": 611.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 562.476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.3CM",
      "code_information": [
        {
          "code": "3600165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 605,
          "minimum": 127.05,
          "maximum": 442.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 407.5425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNOTOMY 046-367",
      "code_information": [
        {
          "code": "3600166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.0889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-SELF LOCKING 4933-0-802",
      "code_information": [
        {
          "code": "3600214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH14 050179",
      "code_information": [
        {
          "code": "3600219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.0889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R501-26",
      "code_information": [
        {
          "code": "3600220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 222.2959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL XS EVF1XSLA",
      "code_information": [
        {
          "code": "3600221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 253,
          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.4269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL S-M EVF1MSLA",
      "code_information": [
        {
          "code": "3600222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 253,
          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.4269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL L EVF1LSLA",
      "code_information": [
        {
          "code": "3600223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 253,
          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.4269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SMLSL",
      "code_information": [
        {
          "code": "3600229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.3225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 8 5 165808",
      "code_information": [
        {
          "code": "3600233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.7229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SZ 0 VLOCM2146",
      "code_information": [
        {
          "code": "3600255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 390,
          "minimum": 81.9,
          "maximum": 285.558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.7134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 BARBED VLOCL0615",
      "code_information": [
        {
          "code": "3600256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 394.07,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X285MM 703583",
      "code_information": [
        {
          "code": "3600270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R502-15",
      "code_information": [
        {
          "code": "3600272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT AR-11114",
      "code_information": [
        {
          "code": "3600273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 187.2675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO 125MM AR-3210-0051",
      "code_information": [
        {
          "code": "3600300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR,SUCTION 8MM 480299",
      "code_information": [
        {
          "code": "3600302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1868,
          "minimum": 392.28,
          "maximum": 1367.7496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1258.3296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-2.3MM INLINE DRILL MOUTH",
      "code_information": [
        {
          "code": "3600308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2463,
          "minimum": 517.23,
          "maximum": 1803.4086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1659.1359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SPIRAL 7000AAO",
      "code_information": [
        {
          "code": "3600310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ONESTEP 5F OSC-5F-12PT/C",
      "code_information": [
        {
          "code": "3600311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 468,
          "minimum": 98.28,
          "maximum": 342.6696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 315.256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NASAL ETOC2 ADT",
      "code_information": [
        {
          "code": "3600315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 277,
          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.5938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48MM EZOUT 7812-048-001K",
      "code_information": [
        {
          "code": "3600316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3419.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-50MM EZOUT 7812-050-001K",
      "code_information": [
        {
          "code": "3600317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3419.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC/SAG 5.5 2296-023-412",
      "code_information": [
        {
          "code": "3600318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 254.6299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FAT TRANS VIALITY-1400",
      "code_information": [
        {
          "code": "3600331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2280.2172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3600343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL 3.5/2.5 AR-8943-14",
      "code_information": [
        {
          "code": "3600344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3998,
          "minimum": 839.58,
          "maximum": 2927.3356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2693.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 MONOTEX T8623",
      "code_information": [
        {
          "code": "3600351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.4136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-VISION SUCTION PROBE",
      "code_information": [
        {
          "code": "3600353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-VISION PROBE ION 490127",
      "code_information": [
        {
          "code": "3600354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 221.6223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 19G BIOPSY",
      "code_information": [
        {
          "code": "3600355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 21G BIOPSY",
      "code_information": [
        {
          "code": "3600356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 23G BIOPSY",
      "code_information": [
        {
          "code": "3600357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 14-16FR",
      "code_information": [
        {
          "code": "3600358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.9051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-ION SWIVEL",
      "code_information": [
        {
          "code": "3600359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 914.7814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 5X356/126MM 03.008.008",
      "code_information": [
        {
          "code": "3600375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1921,
          "minimum": 403.41,
          "maximum": 1406.5562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1294.0317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROC 2.3X230 P99-194-2323",
      "code_information": [
        {
          "code": "3600390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 675.6449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3600412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.4759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUMIDIFIER-CPAP HC325S",
      "code_information": [
        {
          "code": "3600428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE M001141006",
      "code_information": [
        {
          "code": "3600430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1293,
          "minimum": 271.53,
          "maximum": 946.7346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 870.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-2-2.7MM 706200",
      "code_information": [
        {
          "code": "3600436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 949.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-8MM/SD LORD 1088-43-008",
      "code_information": [
        {
          "code": "3600449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2660.1412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-6MM/SD PARA 108843106",
      "code_information": [
        {
          "code": "3600452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2660.1412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER FLX 4150016000",
      "code_information": [
        {
          "code": "3600467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4998,
          "minimum": 1049.58,
          "maximum": 3659.5356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3366.7728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-9X250 STP 4150002090",
      "code_information": [
        {
          "code": "3600471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1465.1322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-FETAL C-SECTION",
      "code_information": [
        {
          "code": "3600474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3781.0515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-BAND POLY CFI-733",
      "code_information": [
        {
          "code": "3600493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PUMP 8\\\" AR-6411",
      "code_information": [
        {
          "code": "3600498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 515.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC OUTFLOW AR-6435",
      "code_information": [
        {
          "code": "3600499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 752,
          "minimum": 157.92,
          "maximum": 550.6144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 506.5652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY M00516071",
      "code_information": [
        {
          "code": "3600502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.1555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VEIN HARVEST VASOVIEW",
      "code_information": [
        {
          "code": "3600503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1476,
          "minimum": 309.96,
          "maximum": 1080.7272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 994.269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURSPLEX DART300 NASAL",
      "code_information": [
        {
          "code": "3600506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURAPLEX DART-REACH600",
      "code_information": [
        {
          "code": "3600507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY O40-403",
      "code_information": [
        {
          "code": "3600508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 4.6X340 P99-110-4634",
      "code_information": [
        {
          "code": "3600519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1885.4736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 11X200 4922-8-200",
      "code_information": [
        {
          "code": "3600545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1786,
          "minimum": 375.06,
          "maximum": 1307.7092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1203.0925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HEMOCON PERF 020271801",
      "code_information": [
        {
          "code": "3600548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 842,
          "minimum": 176.82,
          "maximum": 616.5124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 567.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-SINGLE NEOPRENE M8138",
      "code_information": [
        {
          "code": "3600550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION ADULT",
      "code_information": [
        {
          "code": "3600551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION PED",
      "code_information": [
        {
          "code": "3600552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383592",
      "code_information": [
        {
          "code": "3600553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.8558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-EAR DISP 4015",
      "code_information": [
        {
          "code": "3600557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 203.4344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG STRT AR-7821",
      "code_information": [
        {
          "code": "3600561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1118.8895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 10FL AR-9280NOT",
      "code_information": [
        {
          "code": "3600562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 746.3754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-NANO 2.8X11 AR-9280NSR",
      "code_information": [
        {
          "code": "3600563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 746.3754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-HP EVAC 70 E1CA5874-01",
      "code_information": [
        {
          "code": "3600565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2197,
          "minimum": 461.37,
          "maximum": 1608.6434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1479.9519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-EVAC 70 EICA5872-01",
      "code_information": [
        {
          "code": "3600567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2097,
          "minimum": 440.37,
          "maximum": 1535.4234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1412.5895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE XP EICA8872-01",
      "code_information": [
        {
          "code": "3600568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2093,
          "minimum": 439.53,
          "maximum": 1532.4946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1409.895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PURPLE",
      "code_information": [
        {
          "code": "3600570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY PURPLE",
      "code_information": [
        {
          "code": "3600571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PINK/RED",
      "code_information": [
        {
          "code": "3600574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY YELLOW",
      "code_information": [
        {
          "code": "3600575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY WHITE",
      "code_information": [
        {
          "code": "3600576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION WHITE",
      "code_information": [
        {
          "code": "3600577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION BLUE",
      "code_information": [
        {
          "code": "3600579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION ORANGE",
      "code_information": [
        {
          "code": "3600580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY ORANGE",
      "code_information": [
        {
          "code": "3600581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION GREEN",
      "code_information": [
        {
          "code": "3600582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GUIDE 95CM/9FR STRT",
      "code_information": [
        {
          "code": "3600599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1283.9273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 16MM P45-914-0001",
      "code_information": [
        {
          "code": "3600607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-XL 10MM HEX P45-941-0001",
      "code_information": [
        {
          "code": "3600609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 458.7379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT P45-170-1000",
      "code_information": [
        {
          "code": "3600610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4551.0037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MEASURE STOMA MIC-KEY",
      "code_information": [
        {
          "code": "3600617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENTERAL FEEDING LITE",
      "code_information": [
        {
          "code": "3600618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.9601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-FARREL ENTERAL W BAG",
      "code_information": [
        {
          "code": "3600619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.8766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.7MM AR-7511",
      "code_information": [
        {
          "code": "3600664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 WHITE 48360W",
      "code_information": [
        {
          "code": "3600665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1091.9445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLUE 48360B",
      "code_information": [
        {
          "code": "3600666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1091.9445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 GREEN 48360G",
      "code_information": [
        {
          "code": "3600667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1091.9445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLACK 48360T",
      "code_information": [
        {
          "code": "3600668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1091.9445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-PORTABLE DEVILBISS",
      "code_information": [
        {
          "code": "3600669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2011,
          "minimum": 422.31,
          "maximum": 1472.4542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1354.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WATER-STERILE INHALATION 500ML",
      "code_information": [
        {
          "code": "3600670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-14FR SU130-1239",
      "code_information": [
        {
          "code": "3600671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2016,
          "minimum": 423.36,
          "maximum": 1476.1152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1358.026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-16FR SU130-1240",
      "code_information": [
        {
          "code": "3600672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2016,
          "minimum": 423.36,
          "maximum": 1476.1152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1358.026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X185MM 2351-4218S",
      "code_information": [
        {
          "code": "3600681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 875.7112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 1.7MM DSDS0017",
      "code_information": [
        {
          "code": "3600688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1283.9273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2MM DSDS0020",
      "code_information": [
        {
          "code": "3600689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1283.9273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3600708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 701.9162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.6X150MM AR-8741-16",
      "code_information": [
        {
          "code": "3600710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 413.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,-TR 2X8MM AR-300-B002",
      "code_information": [
        {
          "code": "3600711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1661.8304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X3.5MM AR-8741-14",
      "code_information": [
        {
          "code": "3600715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION AR-200",
      "code_information": [
        {
          "code": "3600717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 265.4079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-3.7MM DRILL AR-2272",
      "code_information": [
        {
          "code": "3600719",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1425,
          "minimum": 299.25,
          "maximum": 1043.385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 959.9142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO POLY M-L 51114V",
      "code_information": [
        {
          "code": "3600722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CADD PCA 108” 21-7391-24",
      "code_information": [
        {
          "code": "3600723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.1688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.102",
      "code_information": [
        {
          "code": "3600736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 X806H",
      "code_information": [
        {
          "code": "3600739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.6679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN PVC 24FR",
      "code_information": [
        {
          "code": "3600749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANCHOR-ENTUIT SUTURE G35562",
      "code_information": [
        {
          "code": "3600750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1342,
          "minimum": 281.82,
          "maximum": 982.6124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 904.0034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT FEEDINGTUBE G3561",
      "code_information": [
        {
          "code": "3600751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 522.7322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LEAD-CATH 4FR 38 383069",
      "code_information": [
        {
          "code": "3600757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-NITINOL 2.0MM",
      "code_information": [
        {
          "code": "3600759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6MM MXM-072-16",
      "code_information": [
        {
          "code": "3600767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1211.8496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6 MXM-072-ISO-16",
      "code_information": [
        {
          "code": "3600768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1211.8496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RCC RMH-T015S",
      "code_information": [
        {
          "code": "3600773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 608.9561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXOFIN FUSION EF70430",
      "code_information": [
        {
          "code": "3600781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 976,
          "minimum": 204.96,
          "maximum": 714.6272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 657.457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 MONOTEX FS-2 T8665",
      "code_information": [
        {
          "code": "3600782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA",
      "code_information": [
        {
          "code": "3600783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 363.757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "XTRAFLANGE-PROVOX 20 FR 7276",
      "code_information": [
        {
          "code": "3600784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 363.757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20 FR 6MM 8277",
      "code_information": [
        {
          "code": "3600785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1951,
          "minimum": 409.71,
          "maximum": 1428.5222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1314.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2006-NS",
      "code_information": [
        {
          "code": "3600786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1965.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-NS",
      "code_information": [
        {
          "code": "3600787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1965.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-LF",
      "code_information": [
        {
          "code": "3600788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1965.6348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE 4.2X130 2351-4213S",
      "code_information": [
        {
          "code": "3600791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 875.7112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-LOCK 4.2X360 2351-4236S",
      "code_information": [
        {
          "code": "3600792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 875.7112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-CARDIOTOMY EL400",
      "code_information": [
        {
          "code": "3600858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 579,
          "minimum": 121.59,
          "maximum": 423.9438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 390.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 34CC LINEAR",
      "code_information": [
        {
          "code": "3600866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4523,
          "minimum": 949.83,
          "maximum": 3311.7406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3046.8014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 40CC MEGA 0",
      "code_information": [
        {
          "code": "3600867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4905,
          "minimum": 1030.05,
          "maximum": 3591.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3304.1257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 50CC MEGA 0",
      "code_information": [
        {
          "code": "3600868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4905,
          "minimum": 1030.05,
          "maximum": 3591.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3304.1257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-8\\\" THD AR-8967KT",
      "code_information": [
        {
          "code": "3600879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1 LMA",
      "code_information": [
        {
          "code": "3600899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 10' 251010J",
      "code_information": [
        {
          "code": "3600900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-STR 4MM P1-AU511",
      "code_information": [
        {
          "code": "3600906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7067,
          "minimum": 1484.07,
          "maximum": 5174.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4760.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1.5 LMA",
      "code_information": [
        {
          "code": "3600907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 3 LMA",
      "code_information": [
        {
          "code": "3600908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 5 LMA",
      "code_information": [
        {
          "code": "3600909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 2 LMA",
      "code_information": [
        {
          "code": "3600910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS MED TRACTION",
      "code_information": [
        {
          "code": "3600912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS LG TRACTION",
      "code_information": [
        {
          "code": "3600913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS SM TRACTION",
      "code_information": [
        {
          "code": "3600914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 130187",
      "code_information": [
        {
          "code": "3600915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SHRT SCREW 6149.1042",
      "code_information": [
        {
          "code": "3600925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EZX 54MM BRXTB540",
      "code_information": [
        {
          "code": "3600938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5636,
          "minimum": 1183.56,
          "maximum": 4126.6792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3796.5449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-TOGA XL 0416-830-100",
      "code_information": [
        {
          "code": "3600948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 909,
          "minimum": 190.89,
          "maximum": 665.5698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 612.3242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20F 10MM 8279",
      "code_information": [
        {
          "code": "3600952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1894,
          "minimum": 397.74,
          "maximum": 1386.7868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1275.8439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS MALLEABLE 4MM",
      "code_information": [
        {
          "code": "3600954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1465.1322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG LIGHT MED C02051",
      "code_information": [
        {
          "code": "3600964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG SMALL C020500",
      "code_information": [
        {
          "code": "3600965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 228MM 56010228",
      "code_information": [
        {
          "code": "3600977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-JONES 3.2MM 56013200",
      "code_information": [
        {
          "code": "3600978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1283.9273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 5.5MM 56015500",
      "code_information": [
        {
          "code": "3600980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1584,
          "minimum": 332.64,
          "maximum": 1159.8048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1067.0204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CRYOTHERAPY FGS-7000",
      "code_information": [
        {
          "code": "3600997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5867,
          "minimum": 1232.07,
          "maximum": 4295.8174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3952.152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXHAUST COLLECT FGS-7015",
      "code_information": [
        {
          "code": "3600999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONN-X 5.5/32-40 LNG 1119.0034",
      "code_information": [
        {
          "code": "3601000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2147.5133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-SUCT&ANTICOAG BT275",
      "code_information": [
        {
          "code": "3601009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.0303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ XF 4.2MM 0909-400-400",
      "code_information": [
        {
          "code": "3601031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 471.5368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 10MM 650.110",
      "code_information": [
        {
          "code": "3601032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-12\\\" THD AR-8967KT-12",
      "code_information": [
        {
          "code": "3601044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 253.2826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS BIPOLAR 2MM",
      "code_information": [
        {
          "code": "3601053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1667,
          "minimum": 350.07,
          "maximum": 1220.5774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1122.9312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CRV 4MM P1-AU550",
      "code_information": [
        {
          "code": "3601055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5301.4209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-360-430 ALLOX2-FH13SE",
      "code_information": [
        {
          "code": "3601056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7446,
          "minimum": 1563.66,
          "maximum": 5451.9612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5015.8043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACENTESIS/PARACENTESI",
      "code_information": [
        {
          "code": "3601066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 701,
          "minimum": 147.21,
          "maximum": 513.2722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 472.2104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G CMNT 0306-150-000",
      "code_information": [
        {
          "code": "3601086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.8272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CMNT 11G 0306-330-000",
      "code_information": [
        {
          "code": "3601087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 642,
          "minimum": 134.82,
          "maximum": 470.0724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 432.4666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TB AR-200",
      "code_information": [
        {
          "code": "3601096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 273.4913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRILL 3X320 P31-951-3032",
      "code_information": [
        {
          "code": "3601107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1963,
          "minimum": 412.23,
          "maximum": 1437.3086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1322.3239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 7X200 P99-110-7019",
      "code_information": [
        {
          "code": "3601108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1885.4736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-110-4630",
      "code_information": [
        {
          "code": "3601109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1885.4736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.8X250 P99-100-3825",
      "code_information": [
        {
          "code": "3601110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1885.4736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-100-4630",
      "code_information": [
        {
          "code": "3601111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1885.4736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-HEAD 17.5 03.404.031S",
      "code_information": [
        {
          "code": "3601120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3893,
          "minimum": 817.53,
          "maximum": 2850.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2622.4182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CENTRAL VENOUS PED",
      "code_information": [
        {
          "code": "3601123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 669,
          "minimum": 140.49,
          "maximum": 489.8418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 450.6545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOD-PROTECTOR 69392",
      "code_information": [
        {
          "code": "3601124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 350,
          "minimum": 73.5,
          "maximum": 256.27,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 235.7684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT ADULT DISP 731",
      "code_information": [
        {
          "code": "3601125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 273,
          "minimum": 57.33,
          "maximum": 199.8906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 183.8994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CHEST VENT HYFIN TWINPACK",
      "code_information": [
        {
          "code": "3601126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-VARISPEED 62-50201",
      "code_information": [
        {
          "code": "3601154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1913,
          "minimum": 401.73,
          "maximum": 1400.6986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1288.6427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.5MM 72202189",
      "code_information": [
        {
          "code": "3601200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STR 14MM/SC 684.424",
      "code_information": [
        {
          "code": "3601216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SUCTION BALLARD 14FR",
      "code_information": [
        {
          "code": "3601234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.9392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 35FR 412351000",
      "code_information": [
        {
          "code": "3601235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.2443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 37FR 412371000",
      "code_information": [
        {
          "code": "3601236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1175.4739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 39FR 412391000",
      "code_information": [
        {
          "code": "3601237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1175.4739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-1.8X450 DIA PT 4933-8-010",
      "code_information": [
        {
          "code": "3601244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 682,
          "minimum": 143.22,
          "maximum": 499.3604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 459.4116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 120MM 4933-1-120",
      "code_information": [
        {
          "code": "3601245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 527,
          "minimum": 110.67,
          "maximum": 385.8694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 354.9998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 150MM 4933-1-150",
      "code_information": [
        {
          "code": "3601246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 527,
          "minimum": 110.67,
          "maximum": 385.8694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 354.9998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SCREW 6149.1040",
      "code_information": [
        {
          "code": "3601255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-IV SW 3000ML BAG S8505",
      "code_information": [
        {
          "code": "3601260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4MM CANN AR-8973-40S",
      "code_information": [
        {
          "code": "3601272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1052.2007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-PIN & PROT P45-610-1000",
      "code_information": [
        {
          "code": "3601289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-10MM P47-950-0001",
      "code_information": [
        {
          "code": "3601290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1933,
          "minimum": 405.93,
          "maximum": 1415.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1302.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-PROTECT P45-600-1000-S",
      "code_information": [
        {
          "code": "3601291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.1138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-AIR+MENISCAL CV 4722",
      "code_information": [
        {
          "code": "3601324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1718.4148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLUE STAPLE GCR40B",
      "code_information": [
        {
          "code": "3601345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1903,
          "minimum": 399.63,
          "maximum": 1393.3766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1281.9065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-GRAFT LG M00236320021",
      "code_information": [
        {
          "code": "3601349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 176,
          "minimum": 36.96,
          "maximum": 128.8672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 118.5578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC SMALL 313-9013W",
      "code_information": [
        {
          "code": "3601350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 190.6356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC MED 313-9014W",
      "code_information": [
        {
          "code": "3601351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 190.6356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC LARGE 313-9015W",
      "code_information": [
        {
          "code": "3601352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 190.6356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-2.5 PRCSN MTCH HD 16CM",
      "code_information": [
        {
          "code": "3601354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1891,
          "minimum": 397.11,
          "maximum": 1384.5902,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1273.823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROCH 1.1MM AR-18700-30",
      "code_information": [
        {
          "code": "3601375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.74,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STEP SOLID 1806-3026S",
      "code_information": [
        {
          "code": "3601387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1432,
          "minimum": 300.72,
          "maximum": 1048.5104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 964.6296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47522",
      "code_information": [
        {
          "code": "3601390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 844.0509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47520",
      "code_information": [
        {
          "code": "3601391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 844.0509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-ENDOCLOT EA230",
      "code_information": [
        {
          "code": "3601393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 592,
          "minimum": 124.32,
          "maximum": 433.4624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.7854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 12\\\" 3.2MM",
      "code_information": [
        {
          "code": "3601397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 399,
          "minimum": 83.79,
          "maximum": 292.1478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 268.776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.25MM  AR-18800-35",
      "code_information": [
        {
          "code": "3601403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 851,
          "minimum": 178.71,
          "maximum": 623.1022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 573.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-10X16X8/12° 1213.6088S",
      "code_information": [
        {
          "code": "3601406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6769,
          "minimum": 1421.49,
          "maximum": 4956.2618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4559.7609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 16X8MM 1128.2408",
      "code_information": [
        {
          "code": "3601407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3040.0651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X14MM 184.014",
      "code_information": [
        {
          "code": "3601408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X16MM 184.016",
      "code_information": [
        {
          "code": "3601409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR SD 4.2X14MM 184.054",
      "code_information": [
        {
          "code": "3601410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI REFLUX",
      "code_information": [
        {
          "code": "3601418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-KANGAROO Y-PORT/PEG",
      "code_information": [
        {
          "code": "3601419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.8899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 18FR 8887605189",
      "code_information": [
        {
          "code": "3601420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 20FR 8887605205",
      "code_information": [
        {
          "code": "3601421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IN/OUTFLOW AR-6436",
      "code_information": [
        {
          "code": "3601433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1031,
          "minimum": 216.51,
          "maximum": 754.8982,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 694.5063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-3X7 AR-9300DS",
      "code_information": [
        {
          "code": "3601434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 413.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON PEG ENFIT",
      "code_information": [
        {
          "code": "3601438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.3415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G-TUBE ENFIT",
      "code_information": [
        {
          "code": "3601440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1234,
          "minimum": 259.14,
          "maximum": 903.5348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 831.252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG ENFIT 24FR M00509061",
      "code_information": [
        {
          "code": "3601441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 475.5785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5020",
      "code_information": [
        {
          "code": "3601445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 846,
          "minimum": 177.66,
          "maximum": 619.4412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 569.8859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOCKWAVE STERILE CABLE",
      "code_information": [
        {
          "code": "3601446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16FR 20CM G01212",
      "code_information": [
        {
          "code": "3601447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-18FR 20CM G01328",
      "code_information": [
        {
          "code": "3601448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO JEJUNAL 8250-22",
      "code_information": [
        {
          "code": "3601452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1577,
          "minimum": 331.17,
          "maximum": 1154.6794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1062.305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 8200-20",
      "code_information": [
        {
          "code": "3601453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 932.2956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10FR 50-7361",
      "code_information": [
        {
          "code": "3601454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 444,
          "minimum": 93.24,
          "maximum": 325.0968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.0891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 18140",
      "code_information": [
        {
          "code": "3601455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 660.1515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN 2.55MM MD 45303155",
      "code_information": [
        {
          "code": "3601456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DLP CORONARY 30315",
      "code_information": [
        {
          "code": "3601479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 510,
          "minimum": 107.1,
          "maximum": 373.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 343.5482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 875,
          "minimum": 183.75,
          "maximum": 640.675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 589.421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 14FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.3415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.3415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC DRG MN12050",
      "code_information": [
        {
          "code": "3601484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1808.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PREFORM-S3-4 39+6MM DWP2396",
      "code_information": [
        {
          "code": "3601576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5471.8478,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 18X7MM 1128.1507",
      "code_information": [
        {
          "code": "3601577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3040.0651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-20X55 8-17 5° 1122.1055",
      "code_information": [
        {
          "code": "3601578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 31589,
          "minimum": 6633.69,
          "maximum": 23129.4658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 21279.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 3X14 AR-8630-14",
      "code_information": [
        {
          "code": "3601580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 2.5X16 AR-8625-16",
      "code_information": [
        {
          "code": "3601581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LP/CRT 1.6X9 AR-18716-09",
      "code_information": [
        {
          "code": "3601582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1206,
          "minimum": 253.26,
          "maximum": 883.0332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 812.3905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CABLE PLATE 94-1200-08",
      "code_information": [
        {
          "code": "3601588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5867,
          "minimum": 1232.07,
          "maximum": 4295.8174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3952.152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1195",
      "code_information": [
        {
          "code": "3601590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 647.3527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ1 CN P2ND1001",
      "code_information": [
        {
          "code": "3601591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1013.1305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-PEDI DSG P2HE2000",
      "code_information": [
        {
          "code": "3601592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8710,
          "minimum": 1829.1,
          "maximum": 6377.462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5867.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BALLARD/NEO BAA2103",
      "code_information": [
        {
          "code": "3601615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.4326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-DF 65MM/RT/STD 6495-2-040",
      "code_information": [
        {
          "code": "3601630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21681,
          "minimum": 4553.01,
          "maximum": 15874.8282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14604.8419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CN/CC 7X45MM 8040-045",
      "code_information": [
        {
          "code": "3601631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1875.3692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-SMALL KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7523,
          "minimum": 1579.83,
          "maximum": 5508.3406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5067.6734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-LARGE KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7523,
          "minimum": 1579.83,
          "maximum": 5508.3406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5067.6734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 11X100MM 4922-8-100",
      "code_information": [
        {
          "code": "3601641",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1743,
          "minimum": 366.03,
          "maximum": 1276.2246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1174.1266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-WOUND CROWN",
      "code_information": [
        {
          "code": "3601647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 530.8157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN RAL 6MM B02236010",
      "code_information": [
        {
          "code": "3601652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1695.5116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN STD 6MM B02236001",
      "code_information": [
        {
          "code": "3601653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1695.5116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL LK 3.5 AR-8943-43",
      "code_information": [
        {
          "code": "3601667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1803.9651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ALEXIS M/L HR105",
      "code_information": [
        {
          "code": "3601692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1175.4739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5 SHORT 6149.1038S",
      "code_information": [
        {
          "code": "3601700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLEY-COUVEL 3-W",
      "code_information": [
        {
          "code": "3601705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.4136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-O3 OXIMETRY CEREBRAL",
      "code_information": [
        {
          "code": "3601707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM",
      "code_information": [
        {
          "code": "3601709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1830.91,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM BOX",
      "code_information": [
        {
          "code": "3601710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2537,
          "minimum": 532.77,
          "maximum": 1857.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1708.9841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 23/M P01-900-2303",
      "code_information": [
        {
          "code": "3601722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1822.1529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ2 CN P2ND1002",
      "code_information": [
        {
          "code": "3601743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1013.1305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 16FR",
      "code_information": [
        {
          "code": "3601752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 660.1515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CV/XS 4MM P1-AU551",
      "code_information": [
        {
          "code": "3601759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5301.4209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 3/10F AR-98300OBT",
      "code_information": [
        {
          "code": "3601764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CIR/BEV P45-940-1001",
      "code_information": [
        {
          "code": "3601766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.0MM",
      "code_information": [
        {
          "code": "3601769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FLIPCUTTER III AR-1204FF",
      "code_information": [
        {
          "code": "3601777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2543,
          "minimum": 534.03,
          "maximum": 1861.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1713.0258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MGS 3MM AR-9628S",
      "code_information": [
        {
          "code": "3601781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-INFANT NEONATE CO2",
      "code_information": [
        {
          "code": "3601783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.7457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCAN 4MM AR-1204D",
      "code_information": [
        {
          "code": "3601799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1261,
          "minimum": 264.81,
          "maximum": 923.3042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 849.4399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-.066CN 2.75MM AR-7000-14",
      "code_information": [
        {
          "code": "3601800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1661.8304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X6\\\" AR-8941-6",
      "code_information": [
        {
          "code": "3601803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X7\\\" AR-8941-7",
      "code_information": [
        {
          "code": "3601804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG ST TR AR-7823",
      "code_information": [
        {
          "code": "3601805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1118.8895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TROCH 1.35MM AR-8737-02",
      "code_information": [
        {
          "code": "3601814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 211.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JTIP 8164-2001-25",
      "code_information": [
        {
          "code": "3601822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRAY AR-200SP",
      "code_information": [
        {
          "code": "3601873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1333.7755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G MIS SHARP 501168",
      "code_information": [
        {
          "code": "3601880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE 6MM BH-220",
      "code_information": [
        {
          "code": "3601882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11846,
          "minimum": 2487.66,
          "maximum": 8673.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7979.7499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMAN.157X9\\\" KI71675",
      "code_information": [
        {
          "code": "3601893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 193,
          "minimum": 40.53,
          "maximum": 141.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.0094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .035X9\\\" DD KI71211",
      "code_information": [
        {
          "code": "3601894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FRACTURE KEX152EB",
      "code_information": [
        {
          "code": "3601895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 13504,
          "minimum": 2835.84,
          "maximum": 9887.6288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9096.6185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-TIB 11X360MM 1822-1136S",
      "code_information": [
        {
          "code": "3601898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5142,
          "minimum": 1079.82,
          "maximum": 3764.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3463.7746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LASER TRACH #5 102004050",
      "code_information": [
        {
          "code": "3601900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1245,
          "minimum": 261.45,
          "maximum": 911.589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 838.6619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-BLOOD COLLECT 04258",
      "code_information": [
        {
          "code": "3601933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 394.07,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77720",
      "code_information": [
        {
          "code": "3601934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 744,
          "minimum": 156.24,
          "maximum": 544.7568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 501.1763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .062X5\\\" 5050-249",
      "code_information": [
        {
          "code": "3601939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 143,
          "minimum": 30.03,
          "maximum": 104.7046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.3282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .045X5\\\" 5050-248",
      "code_information": [
        {
          "code": "3601940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 69.3833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLUTION-WOUND VASHE 16OZ 003",
      "code_information": [
        {
          "code": "3601945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX944",
      "code_information": [
        {
          "code": "3601947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 187.2675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM AO 702473",
      "code_information": [
        {
          "code": "3601950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2131,
          "minimum": 447.51,
          "maximum": 1560.3182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1435.4927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-7MM P20-910-7000",
      "code_information": [
        {
          "code": "3601961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1160.6542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXT-PERCUTANEOUS 9009",
      "code_information": [
        {
          "code": "3601976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 675.6449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 400MM BT 693.060S",
      "code_information": [
        {
          "code": "3601978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 353.6526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM 1032-115-000",
      "code_information": [
        {
          "code": "3601985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10370,
          "minimum": 2177.7,
          "maximum": 7592.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6985.4809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM 2PROBE 9700-020-200",
      "code_information": [
        {
          "code": "3601986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20104,
          "minimum": 4221.84,
          "maximum": 14720.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 13542.5369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-AEOS STERILE PV012SU",
      "code_information": [
        {
          "code": "3601989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 462,
          "minimum": 97.02,
          "maximum": 338.2764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 311.2143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA 22FR 77422",
      "code_information": [
        {
          "code": "3601990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 376.5558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ENDO 5MM 174209",
      "code_information": [
        {
          "code": "3601996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1819,
          "minimum": 381.99,
          "maximum": 1331.8718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1225.3221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 6213-119-070",
      "code_information": [
        {
          "code": "3601997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PURESOME TMD-07",
      "code_information": [
        {
          "code": "3601998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 235.0948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM AR-8943-36",
      "code_information": [
        {
          "code": "3602028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1198,
          "minimum": 251.58,
          "maximum": 877.1756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 807.0016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PED LUMBAR 21G 645",
      "code_information": [
        {
          "code": "3602032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 147.5237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN HEEL 10X10",
      "code_information": [
        {
          "code": "3602037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X C/D",
      "code_information": [
        {
          "code": "3602043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X C/D",
      "code_information": [
        {
          "code": "3602044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 194.0037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X C/D",
      "code_information": [
        {
          "code": "3602045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL C/D",
      "code_information": [
        {
          "code": "3602046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG C/D",
      "code_information": [
        {
          "code": "3602047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED C/D",
      "code_information": [
        {
          "code": "3602048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K SMALL C/D",
      "code_information": [
        {
          "code": "3602049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X A/B",
      "code_information": [
        {
          "code": "3602050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X A/B",
      "code_information": [
        {
          "code": "3602051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X A/B",
      "code_information": [
        {
          "code": "3602052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 194.0037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL A/B",
      "code_information": [
        {
          "code": "3602053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG A/B",
      "code_information": [
        {
          "code": "3602054",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.7475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED A/B",
      "code_information": [
        {
          "code": "3602055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.4136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN CMP 2.2 DSDS0022",
      "code_information": [
        {
          "code": "3602079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1283.9273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-JOINT PREP INST 9914PK01",
      "code_information": [
        {
          "code": "3602083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1582.3428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP 1.1 NT/SM 58820006",
      "code_information": [
        {
          "code": "3602084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 752,
          "minimum": 157.92,
          "maximum": 550.6144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 506.5652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MICA 2X12MM 57SR0212",
      "code_information": [
        {
          "code": "3602085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2772,
          "minimum": 582.12,
          "maximum": 2029.6584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1867.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MICA INST BLADE 57S1MI07",
      "code_information": [
        {
          "code": "3602088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2242,
          "minimum": 470.82,
          "maximum": 1641.5924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1510.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAMPATNCY FGS-0668",
      "code_information": [
        {
          "code": "3602103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRUDI SHAVER TSB4STR",
      "code_information": [
        {
          "code": "3602104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2147.5133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-BIENAIR AQUACARE 1600617",
      "code_information": [
        {
          "code": "3602106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-ORGO IRRIGATION 1502152",
      "code_information": [
        {
          "code": "3602107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 175.8159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-OSTOMY 18665",
      "code_information": [
        {
          "code": "3602109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-CLOSED TUBE 1320-0125S",
      "code_information": [
        {
          "code": "3602113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 646.0054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 724G",
      "code_information": [
        {
          "code": "3602121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0 8756H",
      "code_information": [
        {
          "code": "3602122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.3207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0   8717H",
      "code_information": [
        {
          "code": "3602124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-EVARREST 2x4\\\" EVT5024",
      "code_information": [
        {
          "code": "3602126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4700,
          "minimum": 987,
          "maximum": 3441.34,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3166.0328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-6 LEAD ECG SNAP BR-916PA",
      "code_information": [
        {
          "code": "3602128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1080,
          "minimum": 226.8,
          "maximum": 790.776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 727.5139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE",
      "code_information": [
        {
          "code": "3602129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 872.3431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TRI 4.0MM P1-AU411",
      "code_information": [
        {
          "code": "3602153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7067,
          "minimum": 1484.07,
          "maximum": 5174.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4760.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1175.4739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.3186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 923.5385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1875.3692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 771.9731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 C012D",
      "code_information": [
        {
          "code": "3602196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.4743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1118.8895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2713.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1175.4739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.3186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 923.5385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1875.3692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 771.9731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3164,
          "minimum": 664.44,
          "maximum": 2316.6808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2131.3463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2713.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1118.8895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-END +5 HUM 1830-0005S",
      "code_information": [
        {
          "code": "3602288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1128,
          "minimum": 236.88,
          "maximum": 825.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 759.8479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1175.4739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.3186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 923.5385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1876.0428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 771.9731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT DL 15MM PROBE 9700-015-200",
      "code_information": [
        {
          "code": "3602331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 22350,
          "minimum": 4693.5,
          "maximum": 16364.67,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 15055.4964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2713.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3164,
          "minimum": 664.44,
          "maximum": 2316.6808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2131.3463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2185,
          "minimum": 458.85,
          "maximum": 1599.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1471.8684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2713.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1118.8895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1175.4739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.3186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 923.5385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1875.3692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 771.9731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT 125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5426,
          "minimum": 1139.46,
          "maximum": 3972.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3655.0838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2185,
          "minimum": 458.85,
          "maximum": 1599.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1471.8684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5426,
          "minimum": 1139.46,
          "maximum": 3972.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3655.0838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 13MM 7786713",
      "code_information": [
        {
          "code": "3602404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 7786703",
      "code_information": [
        {
          "code": "3602405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-MDI SPACER M 1082715",
      "code_information": [
        {
          "code": "3602410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRXPERION XP65/115VS",
      "code_information": [
        {
          "code": "3602411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 165.0379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH SZ5/90MM A0A14",
      "code_information": [
        {
          "code": "3602422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON LINEAR 40",
      "code_information": [
        {
          "code": "3602462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5202,
          "minimum": 1092.42,
          "maximum": 3808.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3504.192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 111331",
      "code_information": [
        {
          "code": "3602483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 650.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SKIN CLOSURE CLR602US",
      "code_information": [
        {
          "code": "3602486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1556,
          "minimum": 326.76,
          "maximum": 1139.3032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1048.1589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-RADIAN FACET K 5526061",
      "code_information": [
        {
          "code": "3602487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1514,
          "minimum": 317.94,
          "maximum": 1108.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1019.8667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 11MM 7786711",
      "code_information": [
        {
          "code": "3602491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PELVIC STAB T-PODR",
      "code_information": [
        {
          "code": "3602497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 629.8384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIR-G BL-NOSE 3X900 0101-900S",
      "code_information": [
        {
          "code": "3602503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 844.0509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165MM S0210-200",
      "code_information": [
        {
          "code": "3602508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1940,
          "minimum": 407.4,
          "maximum": 1420.468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1306.8306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OPEN REAMER 03.168.004",
      "code_information": [
        {
          "code": "3602515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8067,
          "minimum": 1694.07,
          "maximum": 5906.6574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5434.1248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3X413MM 03.168.011",
      "code_information": [
        {
          "code": "3602516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3163,
          "minimum": 664.23,
          "maximum": 2315.9486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2130.6727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LOWER 8/+0 END 2330-0000S",
      "code_information": [
        {
          "code": "3602538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1299,
          "minimum": 272.79,
          "maximum": 951.1278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 875.0376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEART LOOP AV 9S44R",
      "code_information": [
        {
          "code": "3602540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 353.6526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-LOW PROFILE 6143.2527",
      "code_information": [
        {
          "code": "3602541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6702,
          "minimum": 1407.42,
          "maximum": 4907.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4514.628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 160MM P45-180-0160",
      "code_information": [
        {
          "code": "3602542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4045,
          "minimum": 849.45,
          "maximum": 2961.749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2724.8091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 160MM P45-112-0140",
      "code_information": [
        {
          "code": "3602543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4551.0037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-G BALL 3X550 P31-955-1550",
      "code_information": [
        {
          "code": "3602544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1963,
          "minimum": 412.23,
          "maximum": 1437.3086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1322.3239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-300MM THRED P45-310-0300",
      "code_information": [
        {
          "code": "3602545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRUTS-QA MOD MD P45-224-0170",
      "code_information": [
        {
          "code": "3602546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6214,
          "minimum": 1304.94,
          "maximum": 4549.8908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4185.8995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INST ARAGONITE MINI-DS",
      "code_information": [
        {
          "code": "3602550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1356.6787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOINT-BALL MOD P45-233-1000",
      "code_information": [
        {
          "code": "3602557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE 1.8 P99-202-1810",
      "code_information": [
        {
          "code": "3602569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 717.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCPP41D",
      "code_information": [
        {
          "code": "3602572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.9259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PRONE LAT STAB 6246.0200",
      "code_information": [
        {
          "code": "3602576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7446,
          "minimum": 1563.66,
          "maximum": 5451.9612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5015.8043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TT 2.4X9.25 AR-8870K",
      "code_information": [
        {
          "code": "3602593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 235,
          "minimum": 49.35,
          "maximum": 172.067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 158.3016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT W/CAP",
      "code_information": [
        {
          "code": "3602596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT 205-212",
      "code_information": [
        {
          "code": "3602597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT WAVE+ 3.9M",
      "code_information": [
        {
          "code": "3602598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3230.0271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT FLEX 2.9MM",
      "code_information": [
        {
          "code": "3602599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3040.0651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT SMOL 2.9MM",
      "code_information": [
        {
          "code": "3602600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3012,
          "minimum": 632.52,
          "maximum": 2205.3864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2028.9555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3602604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4897,
          "minimum": 1028.37,
          "maximum": 3585.5834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3298.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3602606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4897,
          "minimum": 1028.37,
          "maximum": 3585.5834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3298.7367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.2L CN AR-8973-32LS",
      "code_information": [
        {
          "code": "3602614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1052.2007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°RT AR-4068-90R",
      "code_information": [
        {
          "code": "3602617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 984.8383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°LT AR-4068-90L",
      "code_information": [
        {
          "code": "3602618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1034.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°LT AR-4068-45L",
      "code_information": [
        {
          "code": "3602619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1034.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°RT AR-4068-45R",
      "code_information": [
        {
          "code": "3602620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1034.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPLEDAM AR-6530TD",
      "code_information": [
        {
          "code": "3602621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 270.1232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DTRAX SPINAL DX-22-300",
      "code_information": [
        {
          "code": "3602622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3419.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS 11G/5\\\"\\\" 0306-116-000",
      "code_information": [
        {
          "code": "3602624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 774,
          "minimum": 162.54,
          "maximum": 566.7228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 521.385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-OPTIFIX ABSORB 0113126",
      "code_information": [
        {
          "code": "3602652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HAWKINS 18GX15CM G05045",
      "code_information": [
        {
          "code": "3602657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 14FR G00996",
      "code_information": [
        {
          "code": "3602678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 12FR G00995",
      "code_information": [
        {
          "code": "3602679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-MWCE-18S-4/2-TORNADO",
      "code_information": [
        {
          "code": "3602685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1086,
          "minimum": 228.06,
          "maximum": 795.1692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 731.5557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-10-8 MREYE",
      "code_information": [
        {
          "code": "3602686",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-8 MREYE G42423",
      "code_information": [
        {
          "code": "3602687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION MREYE G42414",
      "code_information": [
        {
          "code": "3602690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-5 MREYE G42410",
      "code_information": [
        {
          "code": "3602691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-4 MREYE G42409",
      "code_information": [
        {
          "code": "3602692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-3 MREYE G42408",
      "code_information": [
        {
          "code": "3602693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-2-3 MREYE G42406",
      "code_information": [
        {
          "code": "3602694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 15MM X 15G",
      "code_information": [
        {
          "code": "3602699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1426,
          "minimum": 299.46,
          "maximum": 1044.1172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 960.5878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 25MM X 15G",
      "code_information": [
        {
          "code": "3602700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1426,
          "minimum": 299.46,
          "maximum": 1044.1172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 960.5878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CO 2.10MM NS1806.002 STE",
      "code_information": [
        {
          "code": "3602710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1658,
          "minimum": 348.18,
          "maximum": 1213.9876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1116.8686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2883-01-024",
      "code_information": [
        {
          "code": "3602763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1645,
          "minimum": 345.45,
          "maximum": 1204.469,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1108.1115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC SAW 1.27MM 71440375",
      "code_information": [
        {
          "code": "3602770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 498.4818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X340MM 1806-4260S",
      "code_information": [
        {
          "code": "3602772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1134,
          "minimum": 238.14,
          "maximum": 830.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 763.8896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 13X300MM 351.27",
      "code_information": [
        {
          "code": "3602773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3542,
          "minimum": 743.82,
          "maximum": 2593.4524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2385.9762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 360.05S",
      "code_information": [
        {
          "code": "3602774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4064,
          "minimum": 853.44,
          "maximum": 2975.6608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2737.6079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 38FR 68138",
      "code_information": [
        {
          "code": "3602784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 462,
          "minimum": 97.02,
          "maximum": 338.2764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 311.2143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/15CM CA1815",
      "code_information": [
        {
          "code": "3602790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 30FR 68130",
      "code_information": [
        {
          "code": "3602796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 388.0074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 32FR 68132",
      "code_information": [
        {
          "code": "3602797",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 602,
          "minimum": 126.42,
          "maximum": 440.7844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 405.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 36FR 68136",
      "code_information": [
        {
          "code": "3602798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 388.0074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 34FR 68134",
      "code_information": [
        {
          "code": "3602799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR",
      "code_information": [
        {
          "code": "3602805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 436,
          "minimum": 91.56,
          "maximum": 319.2392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 293.7001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94895",
      "code_information": [
        {
          "code": "3602818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 701.2426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94835",
      "code_information": [
        {
          "code": "3602819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 701.2426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3602851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 860.2178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 16G/15CM CA1615",
      "code_information": [
        {
          "code": "3602858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 14G/11CM CA1411",
      "code_information": [
        {
          "code": "3602859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 X523H",
      "code_information": [
        {
          "code": "3602867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0  X513H",
      "code_information": [
        {
          "code": "3602868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7 W/QC STD TP 71933035",
      "code_information": [
        {
          "code": "3602893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1537.21,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X250 AO 1806-8018S",
      "code_information": [
        {
          "code": "3602902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 774.6676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-W/ NEEDLES #0 SUTURE",
      "code_information": [
        {
          "code": "3602933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2034.3445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-EXTREMITIES UNIVERSAL",
      "code_information": [
        {
          "code": "3602935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1194",
      "code_information": [
        {
          "code": "3602936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 647.3527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ201",
      "code_information": [
        {
          "code": "3602938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2280.2172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ101",
      "code_information": [
        {
          "code": "3602939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2280.2172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 180MM P45-112-0180",
      "code_information": [
        {
          "code": "3602943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4551.0037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 180MM P45-180-0180",
      "code_information": [
        {
          "code": "3602944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4045,
          "minimum": 849.45,
          "maximum": 2961.749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2724.8091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-4H THRED P45-921-0004",
      "code_information": [
        {
          "code": "3602945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2618,
          "minimum": 549.78,
          "maximum": 1916.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1763.5476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CALIBRA 4X165MM 0225-000",
      "code_information": [
        {
          "code": "3602953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2376,
          "minimum": 498.96,
          "maximum": 1739.7072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1600.5306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5MMPINX9.5MMROD 1151-200",
      "code_information": [
        {
          "code": "3602954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3458,
          "minimum": 726.18,
          "maximum": 2531.9476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2329.3918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-9.5 X 9.5MM ROD 1151-200",
      "code_information": [
        {
          "code": "3602955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3458,
          "minimum": 726.18,
          "maximum": 2531.9476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2329.3918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X150MM 1152-150",
      "code_information": [
        {
          "code": "3602956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X200MM 1152-200",
      "code_information": [
        {
          "code": "3602957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X250MM 1152-250",
      "code_information": [
        {
          "code": "3602958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X300 1152-300",
      "code_information": [
        {
          "code": "3602959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN ASSEM 1158-000",
      "code_information": [
        {
          "code": "3602960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6458,
          "minimum": 1356.18,
          "maximum": 4728.5476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4350.2638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VENASEAL CLOSURE VS-404",
      "code_information": [
        {
          "code": "3602966",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3325.0081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-5.5 P20-910-5500",
      "code_information": [
        {
          "code": "3602974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1160.6542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK -.5 P20-915-5500",
      "code_information": [
        {
          "code": "3602976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1160.6542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PROTECT 5.0 P45-198-5000",
      "code_information": [
        {
          "code": "3602978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5320",
      "code_information": [
        {
          "code": "3603015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1167,
          "minimum": 245.07,
          "maximum": 854.4774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 786.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-150MM THRED P45-310-0150",
      "code_information": [
        {
          "code": "3603022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 458.7379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-CUBE 4H P45-925-0004",
      "code_information": [
        {
          "code": "3603023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2738,
          "minimum": 574.98,
          "maximum": 2004.7636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1844.3825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-3/16\\\" SQ P99-000-316P",
      "code_information": [
        {
          "code": "3603028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 8MM P45-914-0003",
      "code_information": [
        {
          "code": "3603029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCRW-POST+NUT SET B0223000",
      "code_information": [
        {
          "code": "3603037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1695.5116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.35MM AR-5050-01",
      "code_information": [
        {
          "code": "3603040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ULTRALOOP-HS FIBER 72205445",
      "code_information": [
        {
          "code": "3603051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 580.6639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM PROBE 9700-020-100",
      "code_information": [
        {
          "code": "3603057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21773,
          "minimum": 4572.33,
          "maximum": 15942.1906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14666.8154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/F P01-900-1702",
      "code_information": [
        {
          "code": "3603060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1822.1529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F40 64611",
      "code_information": [
        {
          "code": "3603068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63306",
      "code_information": [
        {
          "code": "3603069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.6831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63305",
      "code_information": [
        {
          "code": "3603070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.6831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE SMALL",
      "code_information": [
        {
          "code": "3603071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.5312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE LARGE",
      "code_information": [
        {
          "code": "3603072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.5312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE MEDIUM",
      "code_information": [
        {
          "code": "3603073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.5312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYNG SZ4 321400000U",
      "code_information": [
        {
          "code": "3603074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL WIDE",
      "code_information": [
        {
          "code": "3603075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.74,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL FITPACK",
      "code_information": [
        {
          "code": "3603076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.6831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOWS-SOLO FITPACK SLP1SMSLA",
      "code_information": [
        {
          "code": "3603077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X400MM 1152-400",
      "code_information": [
        {
          "code": "3603081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1555.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP427H",
      "code_information": [
        {
          "code": "3603082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOULTION-WOUND VASHE 118ML",
      "code_information": [
        {
          "code": "3603095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 225,
          "minimum": 47.25,
          "maximum": 164.745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 151.5654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ULTRABRAID SZ2 7210915",
      "code_information": [
        {
          "code": "3603096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.2124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-50 COBLATION 72290037",
      "code_information": [
        {
          "code": "3603101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1887,
          "minimum": 396.27,
          "maximum": 1381.6614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1271.1285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3603102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 517,
          "minimum": 108.57,
          "maximum": 378.5474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 348.2636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-5.5 72202530",
      "code_information": [
        {
          "code": "3603103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-HRVST SYS SK27",
      "code_information": [
        {
          "code": "3603104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3781.0515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INST-GUIDE RELEASE SN20",
      "code_information": [
        {
          "code": "3603105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-HK BONE REMOVAL SN25",
      "code_information": [
        {
          "code": "3603107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRIPLE EDGE INST SN21",
      "code_information": [
        {
          "code": "3603108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0 C013D",
      "code_information": [
        {
          "code": "3603114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.8007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-FILSHIE AVM-851J",
      "code_information": [
        {
          "code": "3603115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1434,
          "minimum": 301.14,
          "maximum": 1049.9748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 965.9768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERC SUTURE AR-7267",
      "code_information": [
        {
          "code": "3603119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 14MM 2022-30-014S",
      "code_information": [
        {
          "code": "3603135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1076.4512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 16MM 2022-30-016S",
      "code_information": [
        {
          "code": "3603136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1076.4512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PIN PROT WHT 5027-1-040",
      "code_information": [
        {
          "code": "3603139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREADED CTF03",
      "code_information": [
        {
          "code": "3603177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3603179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3230.0271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3603180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3230.0271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 8F",
      "code_information": [
        {
          "code": "3603181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3230.0271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 9F",
      "code_information": [
        {
          "code": "3603182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3230.0271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 8MM 022108-10",
      "code_information": [
        {
          "code": "3603183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TPR 3MM 5407-FA3-030",
      "code_information": [
        {
          "code": "3603184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1282,
          "minimum": 269.22,
          "maximum": 938.6804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 863.586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 6MM 5820-010-160",
      "code_information": [
        {
          "code": "3603185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1006.3943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RASP-HELI 3.2MM 5120-080-030",
      "code_information": [
        {
          "code": "3603186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1446,
          "minimum": 303.66,
          "maximum": 1058.7612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 974.0603,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 7205306",
      "code_information": [
        {
          "code": "3603188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 306.4989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 1683H",
      "code_information": [
        {
          "code": "3603192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3603196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3050,
          "minimum": 640.5,
          "maximum": 2233.21,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2054.5532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT C0R47",
      "code_information": [
        {
          "code": "3603197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS CFF74",
      "code_information": [
        {
          "code": "3603198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEEDLE WINGED INF WNIS01",
      "code_information": [
        {
          "code": "3603199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED CTF73",
      "code_information": [
        {
          "code": "3603214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANN-VENOUS HI FLO 24FR 69324",
      "code_information": [
        {
          "code": "3603215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 278.2067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A404",
      "code_information": [
        {
          "code": "3603218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 264.7342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR 72201513",
      "code_information": [
        {
          "code": "3603219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 656,
          "minimum": 137.76,
          "maximum": 480.3232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 441.8973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3603221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 615,
          "minimum": 129.15,
          "maximum": 450.303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 414.2788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOVIE-E-Z CLEAN 0014A",
      "code_information": [
        {
          "code": "3603224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SOMFIT 7037-1001-00",
      "code_information": [
        {
          "code": "3603227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MOD 12MM 2022-30-012S",
      "code_information": [
        {
          "code": "3603247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1076.4512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3603277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-ZINC OXIDE REMDEY 4OZ",
      "code_information": [
        {
          "code": "3603279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT X 2.4/45° 378824",
      "code_information": [
        {
          "code": "3603290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 308,
          "minimum": 64.68,
          "maximum": 225.5176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 207.4762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-STR SP 15° 378235",
      "code_information": [
        {
          "code": "3603291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.5996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM BP 0808-115-800",
      "code_information": [
        {
          "code": "3603299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10281,
          "minimum": 2159.01,
          "maximum": 7527.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6925.5283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-11G VP 0605-411-000",
      "code_information": [
        {
          "code": "3603300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2421,
          "minimum": 508.41,
          "maximum": 1772.6562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1630.8437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-10G VP 0605-410-000",
      "code_information": [
        {
          "code": "3603301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2421,
          "minimum": 508.41,
          "maximum": 1772.6562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1630.8437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BL 3X600 AR-9091BK-30S",
      "code_information": [
        {
          "code": "3603303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL 4.2MM AR-9091-42",
      "code_information": [
        {
          "code": "3603304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1921.8493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CM VP 11G 0306-511-000",
      "code_information": [
        {
          "code": "3603319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 604,
          "minimum": 126.84,
          "maximum": 442.2488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 406.8689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5 REAMING 6143.2571",
      "code_information": [
        {
          "code": "3603340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2034.3445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM F/ANCHOR 72203785",
      "code_information": [
        {
          "code": "3603349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1506,
          "minimum": 316.26,
          "maximum": 1102.6932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1014.4777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X5MM 60-16005",
      "code_information": [
        {
          "code": "3603351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 864.9332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X26MM 60-16526",
      "code_information": [
        {
          "code": "3603355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1442,
          "minimum": 302.82,
          "maximum": 1055.8324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 971.3658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X35 92-16135",
      "code_information": [
        {
          "code": "3603356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1863,
          "minimum": 391.23,
          "maximum": 1364.0886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1254.9615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X50/5M 60-15105",
      "code_information": [
        {
          "code": "3603363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1488,
          "minimum": 312.48,
          "maximum": 1089.5136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1002.3525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X110/20M 60-15620",
      "code_information": [
        {
          "code": "3603364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1830.91,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 VICRYL PLUS VCP762D",
      "code_information": [
        {
          "code": "3603378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.1555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13X50/13G NN-2003",
      "code_information": [
        {
          "code": "3603396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14439.1304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL DIST 2.8MM 4040-000",
      "code_information": [
        {
          "code": "3603404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1975,
          "minimum": 414.75,
          "maximum": 1446.095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1330.4074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 1.5X230MM 0109-230",
      "code_information": [
        {
          "code": "3603406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 771.9731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE HAND 415S002350",
      "code_information": [
        {
          "code": "3603407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1672.6084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CIRCUIT NEONATE DUAL LIMB",
      "code_information": [
        {
          "code": "3603429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 754,
          "minimum": 158.34,
          "maximum": 552.0788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 507.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SUCTION TABLE 8Q70R",
      "code_information": [
        {
          "code": "3603430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 633,
          "minimum": 132.93,
          "maximum": 463.4826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 426.404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5X150 CN P41-910-5015",
      "code_information": [
        {
          "code": "3603431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1102.0489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGATION P65-001-0006-SK",
      "code_information": [
        {
          "code": "3603437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1316,
          "minimum": 276.36,
          "maximum": 963.5752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 886.4892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-QUAD TIP 2762-01-0003",
      "code_information": [
        {
          "code": "3603444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2125.2837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2.5CM M00510880",
      "code_information": [
        {
          "code": "3603498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.2443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2CM M00510870",
      "code_information": [
        {
          "code": "3603499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.2443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GENERATOR-RF PROC RLVRFGPR",
      "code_information": [
        {
          "code": "3603504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1243.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ADD ACCESS INST RLV0075",
      "code_information": [
        {
          "code": "3603508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2660.1412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ACCESS INSTRUMENT RLV0045",
      "code_information": [
        {
          "code": "3603510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9838,
          "minimum": 2065.98,
          "maximum": 7203.3836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6627.1129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DAVINCI INSUFF TUBE 470551",
      "code_information": [
        {
          "code": "3603512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1264,
          "minimum": 265.44,
          "maximum": 925.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 851.4607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/10CM NN-8006",
      "code_information": [
        {
          "code": "3603527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 16702,
          "minimum": 3507.42,
          "maximum": 12229.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 11250.868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X60/13G NN-2004",
      "code_information": [
        {
          "code": "3603530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14439.1304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 40X11 SM-4011M",
      "code_information": [
        {
          "code": "3603538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ALLOGRAFT-22.5MM ABS-4057D-225",
      "code_information": [
        {
          "code": "3603542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5686,
          "minimum": 1194.06,
          "maximum": 4163.2892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3830.2261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL-1.5x48MM 03.130.212",
      "code_information": [
        {
          "code": "3603544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP76",
      "code_information": [
        {
          "code": "3603545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.2182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE 9X102 HTOE 05-306",
      "code_information": [
        {
          "code": "3603547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 265.4079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.35X150 AR-8943-01S",
      "code_information": [
        {
          "code": "3603548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.74,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLECTOR-SPECIMEN NN-9002",
      "code_information": [
        {
          "code": "3603569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 471.5368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/13CM NN-8007",
      "code_information": [
        {
          "code": "3603587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 18660,
          "minimum": 3918.6,
          "maximum": 13662.852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 12569.8238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X95/13G NN-2006",
      "code_information": [
        {
          "code": "3603588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14439.1304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X75/13G NN-2005",
      "code_information": [
        {
          "code": "3603589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14439.1304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-MYRID NICO NN-9001",
      "code_information": [
        {
          "code": "3603590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 7FRX65C",
      "code_information": [
        {
          "code": "3603592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1624,
          "minimum": 341.04,
          "maximum": 1189.0928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1093.9654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 5FRX50C",
      "code_information": [
        {
          "code": "3603593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1624,
          "minimum": 341.04,
          "maximum": 1189.0928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1093.9654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 9FRX65C",
      "code_information": [
        {
          "code": "3603594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1882,
          "minimum": 395.22,
          "maximum": 1378.0004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1267.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-20-22FR/45CM G52835",
      "code_information": [
        {
          "code": "3603768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1759,
          "minimum": 369.39,
          "maximum": 1287.9398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1184.9046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16-18FR/45CM G52834",
      "code_information": [
        {
          "code": "3603769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1759,
          "minimum": 369.39,
          "maximum": 1287.9398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1184.9046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-32-35MM 102024003",
      "code_information": [
        {
          "code": "3603771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.4X27 ST 60-14126",
      "code_information": [
        {
          "code": "3603794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 749.0699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOWN-WARMING BEAR PAW 81001",
      "code_information": [
        {
          "code": "3603809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPYSCOPE DS II M00546610",
      "code_information": [
        {
          "code": "3603810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12212,
          "minimum": 2564.52,
          "maximum": 8941.6264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8226.2963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-EHL 1.9F 375CM M00546620",
      "code_information": [
        {
          "code": "3603814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2879,
          "minimum": 604.59,
          "maximum": 2108.0038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1939.3635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONEMILL MD 5420-MED-000",
      "code_information": [
        {
          "code": "3603815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3354,
          "minimum": 704.34,
          "maximum": 2455.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2259.3349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CRV DIAMOND 15° 1600650",
      "code_information": [
        {
          "code": "3603818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CYLINDER 60° 1600578",
      "code_information": [
        {
          "code": "3603819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.9X27MM 60-19126",
      "code_information": [
        {
          "code": "3603820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 749.0699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X200MM P99-192-1620",
      "code_information": [
        {
          "code": "3603836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 675.6449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2.0 3846T",
      "code_information": [
        {
          "code": "3603837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y415H",
      "code_information": [
        {
          "code": "3603838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 7-0 Z135H",
      "code_information": [
        {
          "code": "3603876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 273,
          "minimum": 57.33,
          "maximum": 199.8906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 183.8994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 45X6 SM-4506",
      "code_information": [
        {
          "code": "3603888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-38MM ARS743201",
      "code_information": [
        {
          "code": "3603895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1058.2633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-14X127MM ARS743303",
      "code_information": [
        {
          "code": "3603897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1058.2633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE .9MM 57S90005",
      "code_information": [
        {
          "code": "3603901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 434.4875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE 1.4MM 57S90004",
      "code_information": [
        {
          "code": "3603902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 434.4875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM MXM-072-19",
      "code_information": [
        {
          "code": "3603904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1211.8496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-76/3 ARS743202",
      "code_information": [
        {
          "code": "3603910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1058.2633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 8.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603923",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 6.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SM CHLD NR34015813",
      "code_information": [
        {
          "code": "3603926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.9525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015814",
      "code_information": [
        {
          "code": "3603927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.9525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PRO-FLOW NR37000145",
      "code_information": [
        {
          "code": "3603928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SPO2 ADULT NR37004030",
      "code_information": [
        {
          "code": "3603929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.5635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMETRY EM951160CP",
      "code_information": [
        {
          "code": "3603931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.4193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ADULT NR34015818",
      "code_information": [
        {
          "code": "3603932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASALNR354S5011",
      "code_information": [
        {
          "code": "3603933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.7438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015816",
      "code_information": [
        {
          "code": "3603934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG WEBB NR104B1420",
      "code_information": [
        {
          "code": "3603935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.2447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-EEG 8OZ NR10200005",
      "code_information": [
        {
          "code": "3603936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 529,
          "minimum": 111.09,
          "maximum": 387.3338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 356.3471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUPREP-4OZ TUBE NR10210004",
      "code_information": [
        {
          "code": "3603937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.4326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THERMOCAN NR34015808",
      "code_information": [
        {
          "code": "3603938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.7438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR/6.7MM 80220",
      "code_information": [
        {
          "code": "3603955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 260.6925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CLEARVUE LARYNG #3",
      "code_information": [
        {
          "code": "3603957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.7457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NOMOLINE LH NASAL/ORAL",
      "code_information": [
        {
          "code": "3603958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.1138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 22FR BE2050",
      "code_information": [
        {
          "code": "3603960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 802.2862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 18FR BE6050",
      "code_information": [
        {
          "code": "3603961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 802.2862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LITHOTRIPER PROBE 3.9MM",
      "code_information": [
        {
          "code": "3603972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4400,
          "minimum": 924,
          "maximum": 3221.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2963.9456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T-15 TORQUE 702750",
      "code_information": [
        {
          "code": "3603979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3611,
          "minimum": 758.31,
          "maximum": 2643.9742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2432.4563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIMITER-TORQUE 2.5NM 702760",
      "code_information": [
        {
          "code": "3603985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4015,
          "minimum": 843.15,
          "maximum": 2939.783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2704.6004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/15 STPL THN00482",
      "code_information": [
        {
          "code": "3603988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2099,
          "minimum": 440.79,
          "maximum": 1536.8878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1413.9368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/20 STPL THN00483",
      "code_information": [
        {
          "code": "3603989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2099,
          "minimum": 440.79,
          "maximum": 1536.8878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1413.9368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA 22.5FR 7275",
      "code_information": [
        {
          "code": "3604022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM*CLEARIFY 21-345",
      "code_information": [
        {
          "code": "3604025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 CHROMIC GUT 792G",
      "code_information": [
        {
          "code": "3604027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 168.406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-NANO 29.5X7MM SM-3115",
      "code_information": [
        {
          "code": "3604043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-MET 20MM MPN20120",
      "code_information": [
        {
          "code": "3604048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHAL 20MM MPN20020",
      "code_information": [
        {
          "code": "3604049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM SHT MSTD1030",
      "code_information": [
        {
          "code": "3604050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CIRCUMCISION 1.45CM",
      "code_information": [
        {
          "code": "3604060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 605,
          "minimum": 127.05,
          "maximum": 442.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 407.5425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE DUAL 844023S",
      "code_information": [
        {
          "code": "3604137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 291,
          "minimum": 61.11,
          "maximum": 213.0702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 196.0246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE SINGLE 800099S",
      "code_information": [
        {
          "code": "3604138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.2239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 2X200 MSG20200",
      "code_information": [
        {
          "code": "3604156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.6 F/5.5MM MSN10013",
      "code_information": [
        {
          "code": "3604157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1830.91,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM LNG MSTD0030",
      "code_information": [
        {
          "code": "3604158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA-G GENERATION 2",
      "code_information": [
        {
          "code": "3604162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10740,
          "minimum": 2255.4,
          "maximum": 7863.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7234.7218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-STAPLE SZ THN00292",
      "code_information": [
        {
          "code": "3604165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1356.6787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 5.0MM 3100-01-0005",
      "code_information": [
        {
          "code": "3604167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2261.3558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 2.4MM 2900-04-0229",
      "code_information": [
        {
          "code": "3604168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1431,
          "minimum": 300.51,
          "maximum": 1047.7782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 963.9559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-6.5MM 3100-01-0007",
      "code_information": [
        {
          "code": "3604169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2261.3558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-7X90 3200-01-7090",
      "code_information": [
        {
          "code": "3604170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 15795,
          "minimum": 3316.95,
          "maximum": 11565.099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 10639.8911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SONATA DE-001-10",
      "code_information": [
        {
          "code": "3604172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 877,
          "minimum": 184.17,
          "maximum": 642.1394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 590.7682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS BONE BX 0306-115-000",
      "code_information": [
        {
          "code": "3604196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 798,
          "minimum": 167.58,
          "maximum": 584.2956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 537.552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-DSG XS 2.5MM P1-AU514",
      "code_information": [
        {
          "code": "3604197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5301.4209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DISTRACTOR 12MM 02.600.022",
      "code_information": [
        {
          "code": "3604198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 668.235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-#0/8\\\"\\\" GREEN VLOCA008L",
      "code_information": [
        {
          "code": "3604209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1317,
          "minimum": 276.57,
          "maximum": 964.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 887.1628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VICRYL VCP104G",
      "code_information": [
        {
          "code": "3604215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.7798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX977",
      "code_information": [
        {
          "code": "3604217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.5597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MINITAPE-LOOPED 72205435",
      "code_information": [
        {
          "code": "3604218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 913,
          "minimum": 191.73,
          "maximum": 668.4986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 615.0187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATE STD 20MM M0056183",
      "code_information": [
        {
          "code": "3604224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 297,
          "minimum": 62.37,
          "maximum": 217.4634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.0663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ACESSA 7300",
      "code_information": [
        {
          "code": "3604227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14892,
          "minimum": 3127.32,
          "maximum": 10903.9224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 10031.6086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-HEAD SILVERMAN SZ F",
      "code_information": [
        {
          "code": "3604228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X12MM AR-300-B003",
      "code_information": [
        {
          "code": "3604244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1661.8304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 3.1X20MM AR-300-B202",
      "code_information": [
        {
          "code": "3604247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1661.8304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUT 2 P41-960-0020",
      "code_information": [
        {
          "code": "3604263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1160.6542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5.5X150 CN P41-910-5515",
      "code_information": [
        {
          "code": "3604264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1102.0489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X150 CN P41-910-4015",
      "code_information": [
        {
          "code": "3604265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1102.0489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-GPS LONG 6143.2515",
      "code_information": [
        {
          "code": "3604278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6702,
          "minimum": 1407.42,
          "maximum": 4907.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4514.628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 8.0",
      "code_information": [
        {
          "code": "3604284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 7.5",
      "code_information": [
        {
          "code": "3604285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED",
      "code_information": [
        {
          "code": "3604286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER TRACH PORTEX 100",
      "code_information": [
        {
          "code": "3604287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEMALE TO FEMALE",
      "code_information": [
        {
          "code": "3604289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-1.8MM PERK AR-3610PK-3",
      "code_information": [
        {
          "code": "3604294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1586,
          "minimum": 333.06,
          "maximum": 1161.2692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1068.3677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 6X7 AR-6535TD",
      "code_information": [
        {
          "code": "3604297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 270.1232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SR8 GEMINI AR-6572",
      "code_information": [
        {
          "code": "3604301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 270.1232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLSRE SKN 22CM EF70401",
      "code_information": [
        {
          "code": "3604305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 711,
          "minimum": 149.31,
          "maximum": 520.5942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.9467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH 14 1/4\\\" 020116801",
      "code_information": [
        {
          "code": "3604307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.0793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-TISSUE HIGH EX71010",
      "code_information": [
        {
          "code": "3604311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.2239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7/F 2.4 AR-8916-18",
      "code_information": [
        {
          "code": "3604317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.7361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-WIRE FIX XL 76-10104",
      "code_information": [
        {
          "code": "3604319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1375,
          "minimum": 288.75,
          "maximum": 1006.775,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 926.233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR PEDIATRIC S-1003",
      "code_information": [
        {
          "code": "3604329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 264,
          "minimum": 55.44,
          "maximum": 193.3008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 177.8367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT SHORT 71-6130S",
      "code_information": [
        {
          "code": "3604330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10354,
          "minimum": 2174.34,
          "maximum": 7581.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6974.7029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 4H 76-10140",
      "code_information": [
        {
          "code": "3604333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1139.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 2H 76-10125",
      "code_information": [
        {
          "code": "3604334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1139.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 200MM 76-11200",
      "code_information": [
        {
          "code": "3604335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 775.3412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 115MM 76-11115",
      "code_information": [
        {
          "code": "3604337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 934,
          "minimum": 196.14,
          "maximum": 683.8748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 629.1648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FH 4.2MM AR-9091F-42",
      "code_information": [
        {
          "code": "3604351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1921.8493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CON 4.3X13MM AR-300-B101",
      "code_information": [
        {
          "code": "3604352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2470,
          "minimum": 518.7,
          "maximum": 1808.534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1663.8513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE SKIN EF70466",
      "code_information": [
        {
          "code": "3604355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 933,
          "minimum": 195.93,
          "maximum": 683.1426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 628.4912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEN-ADHESIVE EP70412",
      "code_information": [
        {
          "code": "3604356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACTIVALVE-PROVOX STRONG 7161",
      "code_information": [
        {
          "code": "3604357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2660.1412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET ACCESS INST LV3 RLV0055",
      "code_information": [
        {
          "code": "3604369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12997,
          "minimum": 2729.37,
          "maximum": 9516.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8755.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.6X200 AR-5050K-1",
      "code_information": [
        {
          "code": "3604376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM C P01-901-0901-S",
      "code_information": [
        {
          "code": "3604385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1822.1529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET SCREW T7 5560010000",
      "code_information": [
        {
          "code": "3604395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 594.81,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-FOGARTY DSOFT33",
      "code_information": [
        {
          "code": "3604398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.1783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-DRAIN/FLUSH LL AFA-LL",
      "code_information": [
        {
          "code": "3604403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #4",
      "code_information": [
        {
          "code": "3604406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 273.4913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #3",
      "code_information": [
        {
          "code": "3604407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 273.4913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-6 THD/10 HEX 76-10180",
      "code_information": [
        {
          "code": "3604415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 235,
          "minimum": 49.35,
          "maximum": 172.067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 158.3016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-FLANGE 10HX 76-10182",
      "code_information": [
        {
          "code": "3604416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.1916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD +3OS/25MM MWJ007",
      "code_information": [
        {
          "code": "3604423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5858,
          "minimum": 1230.18,
          "maximum": 4289.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3946.0894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODEL-REV BONE MWJ015",
      "code_information": [
        {
          "code": "3604424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.0 A-3938",
      "code_information": [
        {
          "code": "3604432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2061,
          "minimum": 432.81,
          "maximum": 1509.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.3391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 16FR 26-016",
      "code_information": [
        {
          "code": "3604433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 612.9978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 12FR 26-012",
      "code_information": [
        {
          "code": "3604434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 612.9978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 18FR 26-018",
      "code_information": [
        {
          "code": "3604435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 612.9978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-NYLON 11MM/265ML CD005",
      "code_information": [
        {
          "code": "3604438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.571,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-6X150 CN P41-910-6015",
      "code_information": [
        {
          "code": "3604457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1102.0489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CAL 5.5MM S0288-200",
      "code_information": [
        {
          "code": "3604470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2470,
          "minimum": 518.7,
          "maximum": 1808.534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1663.8513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.6MM TRC AR-18700-71",
      "code_information": [
        {
          "code": "3604479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.4136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO",
      "code_information": [
        {
          "code": "3604489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 686,
          "minimum": 144.06,
          "maximum": 502.2892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 462.1061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1069210",
      "code_information": [
        {
          "code": "3604490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.2239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-HO 7/1.6X80 P99-205-1608",
      "code_information": [
        {
          "code": "3604512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 717.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GRAFT SIZING AR-1676ST",
      "code_information": [
        {
          "code": "3604518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMANN .157X9\\\"\\\" KI71615",
      "code_information": [
        {
          "code": "3604550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.7039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL SP-78105",
      "code_information": [
        {
          "code": "3604567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 858.197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 1MM 5820-013-010",
      "code_information": [
        {
          "code": "3604568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 860.2178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 12X18/2 DS24",
      "code_information": [
        {
          "code": "3604569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 769,
          "minimum": 161.49,
          "maximum": 563.0618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 518.0169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/0 DS26",
      "code_information": [
        {
          "code": "3604570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 832,
          "minimum": 174.72,
          "maximum": 609.1904,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 560.4552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/2 DS28",
      "code_information": [
        {
          "code": "3604571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 815,
          "minimum": 171.15,
          "maximum": 596.743,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 549.0036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 29/37 TF2937O",
      "code_information": [
        {
          "code": "3604581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.9106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-AMPLATZ 8F M0062601010",
      "code_information": [
        {
          "code": "3604584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 481,
          "minimum": 101.01,
          "maximum": 352.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 324.0131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-33MM LF EVERGRIP33",
      "code_information": [
        {
          "code": "3604594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 359,
          "minimum": 75.39,
          "maximum": 262.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEM 19F/6.3 96570-119",
      "code_information": [
        {
          "code": "3604596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2245,
          "minimum": 471.45,
          "maximum": 1643.789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1512.2859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 19F/6.3MM 96530-119",
      "code_information": [
        {
          "code": "3604597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1672.6084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 21F/7MM 96530-121",
      "code_information": [
        {
          "code": "3604598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1672.6084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WHITE 15X12MM DLP-W11",
      "code_information": [
        {
          "code": "3604599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-YELLOW 15X12MM DLP-S11",
      "code_information": [
        {
          "code": "3604600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-11MM 261222",
      "code_information": [
        {
          "code": "3604605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1803.9651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 650-750CC SZHP68650",
      "code_information": [
        {
          "code": "3604611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 550-640CC SZHP68550",
      "code_information": [
        {
          "code": "3604612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 425-455CC SZHP68425",
      "code_information": [
        {
          "code": "3604613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.6583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 320-340CC SZHP68320",
      "code_information": [
        {
          "code": "3604614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 369.8196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 200-260CC SZHP68200",
      "code_information": [
        {
          "code": "3604615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 750-800CC SZHP68750",
      "code_information": [
        {
          "code": "3604616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 536.2047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 2MM 5820-010-120",
      "code_information": [
        {
          "code": "3604621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 3MM 5820-010-130",
      "code_information": [
        {
          "code": "3604622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 4MM 5820-010-140",
      "code_information": [
        {
          "code": "3604623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 3MM 5820-012-030",
      "code_information": [
        {
          "code": "3604624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 860.2178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 4MM 5820-012-040",
      "code_information": [
        {
          "code": "3604625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1006.3943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 3 5820-013-030",
      "code_information": [
        {
          "code": "3604626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 4 5820-013-040",
      "code_information": [
        {
          "code": "3604627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 919.4968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SAHARA S-1150-08LF",
      "code_information": [
        {
          "code": "3604628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1182,
          "minimum": 248.22,
          "maximum": 865.4604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 796.2236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 20FR 123120",
      "code_information": [
        {
          "code": "3604629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.8064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12X150MM FE CFF71",
      "code_information": [
        {
          "code": "3604631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.2333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X150MM FE CFF01",
      "code_information": [
        {
          "code": "3604632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X100MM BLADE CFB03",
      "code_information": [
        {
          "code": "3604633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 9MM 022109-10",
      "code_information": [
        {
          "code": "3604634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 10MM 022110-10",
      "code_information": [
        {
          "code": "3604635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 12MM 022112-10",
      "code_information": [
        {
          "code": "3604636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 14MM 022114-10",
      "code_information": [
        {
          "code": "3604637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.3415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 16MM 022116-10",
      "code_information": [
        {
          "code": "3604638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC 3-0 VLOCM0644",
      "code_information": [
        {
          "code": "3604653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 364.4306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO BULL M0068332451",
      "code_information": [
        {
          "code": "3604654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 359.0416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0 M0068331371",
      "code_information": [
        {
          "code": "3604655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 359.0416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-JP SUCT 10MM SU130-1311",
      "code_information": [
        {
          "code": "3604656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 10F SU130-402D",
      "code_information": [
        {
          "code": "3604657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 127,
          "minimum": 26.67,
          "maximum": 92.9894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.5502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MUSCLE-TRAINING DEVICE",
      "code_information": [
        {
          "code": "3604659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 222.2959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ACORN 5MM 5820-030-550",
      "code_information": [
        {
          "code": "3604667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1006.3943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERY 2X14MM 31200",
      "code_information": [
        {
          "code": "3604670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 594.81,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERY 1.5X14MM 31150",
      "code_information": [
        {
          "code": "3604671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 594.81,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCES 8MM IAS8-120LP",
      "code_information": [
        {
          "code": "3604725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 942,
          "minimum": 197.82,
          "maximum": 689.7324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 634.5538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM ECS29B",
      "code_information": [
        {
          "code": "3604726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2143,
          "minimum": 450.03,
          "maximum": 1569.1046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1443.5762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOULDER LG/18-19.5\\\"\\\"",
      "code_information": [
        {
          "code": "3604728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 434.4875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOULDER M/16.5-18\\\"\\\"",
      "code_information": [
        {
          "code": "3604729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 434.4875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4MM 080-403",
      "code_information": [
        {
          "code": "3604730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.1005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LARGE COMBO AR-8964-07",
      "code_information": [
        {
          "code": "3604737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1732.2,
          "minimum": 363.762,
          "maximum": 1268.3168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1166.8515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN LG AR-8964-08",
      "code_information": [
        {
          "code": "3604738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1396.5,
          "minimum": 293.265,
          "maximum": 1022.5173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 940.7159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ATTACH-ROD LG CLMP AR-8964-09",
      "code_information": [
        {
          "code": "3604739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1309,
          "minimum": 274.89,
          "maximum": 958.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 881.7738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 100 AR-8964R-100",
      "code_information": [
        {
          "code": "3604740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591.5,
          "minimum": 124.215,
          "maximum": 433.0963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.4486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 250 AR-8964R-250",
      "code_information": [
        {
          "code": "3604741",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591.5,
          "minimum": 124.215,
          "maximum": 433.0963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.4486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 300 AR-8964R-300",
      "code_information": [
        {
          "code": "3604742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 665,
          "minimum": 139.65,
          "maximum": 486.913,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 447.96,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 3.5X195MM AR-8964-10",
      "code_information": [
        {
          "code": "3604743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 332.5,
          "minimum": 69.825,
          "maximum": 243.4565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 223.98,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-END CAP AR-8964-22",
      "code_information": [
        {
          "code": "3604744",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REMV FIBULOCK AR-8973RK",
      "code_information": [
        {
          "code": "3604749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6093,
          "minimum": 1279.53,
          "maximum": 4461.2946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4104.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3604769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 701.9162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LARGE COMBO AR-8964-07",
      "code_information": [
        {
          "code": "3604775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2237.7789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN LG AR-8964-08",
      "code_information": [
        {
          "code": "3604776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1803.9651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ATTACH-ROD LG CLMP AR-8964-09",
      "code_information": [
        {
          "code": "3604777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2510,
          "minimum": 527.1,
          "maximum": 1837.822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1690.7962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 3.5X195MM AR-8964-10",
      "code_information": [
        {
          "code": "3604781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 668.235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-END CAP AR-8964-22",
      "code_information": [
        {
          "code": "3604782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD CTR/25MM MWJ005",
      "code_information": [
        {
          "code": "3604783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5858,
          "minimum": 1230.18,
          "maximum": 4289.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3946.0894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3X215MM 542053",
      "code_information": [
        {
          "code": "3604785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1886,
          "minimum": 396.06,
          "maximum": 1380.9292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1270.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X215MM 542051",
      "code_information": [
        {
          "code": "3604786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1776,
          "minimum": 372.96,
          "maximum": 1300.3872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1196.3562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPM-SOFT GOODS",
      "code_information": [
        {
          "code": "3604787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBGAUZE*SURGITUBE SZ 5/8\\\"",
      "code_information": [
        {
          "code": "3604794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 95.6546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR XS 11MM 10/BX",
      "code_information": [
        {
          "code": "3604795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 592,
          "minimum": 124.32,
          "maximum": 433.4624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.7854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR Y 1/4x1/4x1/4",
      "code_information": [
        {
          "code": "3604798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.2447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO HF 125 AR-3210-0052",
      "code_information": [
        {
          "code": "3604799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 696.5,
          "minimum": 146.265,
          "maximum": 509.9773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 469.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.5X215MM 542021",
      "code_information": [
        {
          "code": "3604823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1885,
          "minimum": 395.85,
          "maximum": 1380.197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1269.7812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT AO 93MM 542031",
      "code_information": [
        {
          "code": "3604824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3667,
          "minimum": 770.07,
          "maximum": 2684.9774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2470.1792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT AO 180MM 542032",
      "code_information": [
        {
          "code": "3604825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2660.1412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 3.5X135MM 542022",
      "code_information": [
        {
          "code": "3604832",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1664,
          "minimum": 349.44,
          "maximum": 1218.3808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.9103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165 AR-9095-43S",
      "code_information": [
        {
          "code": "3604868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1941,
          "minimum": 407.61,
          "maximum": 1421.2002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1307.5042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SX DRY 13CM PSS13DF-5",
      "code_information": [
        {
          "code": "3604876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1671,
          "minimum": 350.91,
          "maximum": 1223.5062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1125.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD T-MAX 7210559",
      "code_information": [
        {
          "code": "3604877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 270.1232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 542000",
      "code_information": [
        {
          "code": "3604891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1626,
          "minimum": 341.46,
          "maximum": 1190.5572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1095.3126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER 60-6085-201A",
      "code_information": [
        {
          "code": "3604912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 572.5804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XL/19.5-22\\\"\\\"",
      "code_information": [
        {
          "code": "3604916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 434.4875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH 6MM NIM 8229706",
      "code_information": [
        {
          "code": "3604917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1858.5286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH 8MM NIM 8229708",
      "code_information": [
        {
          "code": "3604918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1858.5286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-LEAD 518-024",
      "code_information": [
        {
          "code": "3604919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-BULLDOG LEAD LR-LED01",
      "code_information": [
        {
          "code": "3604933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2457,
          "minimum": 515.97,
          "maximum": 1799.0154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1655.0942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 7X7 AR-6570TD",
      "code_information": [
        {
          "code": "3604936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 270.1232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X125MM 542002",
      "code_information": [
        {
          "code": "3604942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1702,
          "minimum": 357.42,
          "maximum": 1246.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1146.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-NEURO PDCMF-BP-001",
      "code_information": [
        {
          "code": "3604949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1243.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRITOME 3WAY SN31",
      "code_information": [
        {
          "code": "3604952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.7772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEXUS CONNECTORS BP6866N",
      "code_information": [
        {
          "code": "3604957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.3358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-LEG SM/16-20\\\"\\\" LS101",
      "code_information": [
        {
          "code": "3604958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.1118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 5-0 VCP834G",
      "code_information": [
        {
          "code": "3604959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-SINSKEY 45 /10MM 581442",
      "code_information": [
        {
          "code": "3604965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 371,
          "minimum": 77.91,
          "maximum": 271.6462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.9145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-AGILIS HISPRO DS3A001",
      "code_information": [
        {
          "code": "3604978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 281.5748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LONG INSERTION 40555",
      "code_information": [
        {
          "code": "3604987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3349,
          "minimum": 703.29,
          "maximum": 2452.1378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2255.9668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY VIAL HH9006",
      "code_information": [
        {
          "code": "3604989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3536,
          "minimum": 742.56,
          "maximum": 2589.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2381.9345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRL 4MM CLOSED AR-1595TC",
      "code_information": [
        {
          "code": "3605014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 923.5385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.5X250 SQC 76-10047",
      "code_information": [
        {
          "code": "3605028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2009,
          "minimum": 421.89,
          "maximum": 1470.9898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1353.3106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM CENTERING 76-10210",
      "code_information": [
        {
          "code": "3605029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 934,
          "minimum": 196.14,
          "maximum": 683.8748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 629.1648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 5H 76-10145",
      "code_information": [
        {
          "code": "3605031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1139.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-6X8MM RANCHO 76-10165",
      "code_information": [
        {
          "code": "3605032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 253.2826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-180MM BUTT 71-61180",
      "code_information": [
        {
          "code": "3605034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1139.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-150MM BUTT 71-61150",
      "code_information": [
        {
          "code": "3605035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1139.7718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARCH-FOOT 150MM 71-90150",
      "code_information": [
        {
          "code": "3605036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5854,
          "minimum": 1229.34,
          "maximum": 4286.2988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3943.3949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FOOT 150MM LONG 71-6100L",
      "code_information": [
        {
          "code": "3605037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9905,
          "minimum": 2080.05,
          "maximum": 7252.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6672.2457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 155MM 71-10155",
      "code_information": [
        {
          "code": "3605038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6752,
          "minimum": 1417.92,
          "maximum": 4943.8144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4548.3092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 ETHIBOND 10X86N",
      "code_information": [
        {
          "code": "3605039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 484,
          "minimum": 101.64,
          "maximum": 354.3848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 326.034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-STONE COLLECT XUSM0031",
      "code_information": [
        {
          "code": "3605040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 503,
          "minimum": 105.63,
          "maximum": 368.2966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.8329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AP LNG/LT AR-8954-10",
      "code_information": [
        {
          "code": "3605076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3379,
          "minimum": 709.59,
          "maximum": 2474.1038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2276.1755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-GIGLI SAW 260-104",
      "code_information": [
        {
          "code": "3605086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IMPELLA AXILLARY 0052-0011",
      "code_information": [
        {
          "code": "3605088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURESTEP MALE EXT CATH",
      "code_information": [
        {
          "code": "3605089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURESTEP MALE EXT CATH",
      "code_information": [
        {
          "code": "3605090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.5009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV 22G X 2.5\\\" 4251622-02",
      "code_information": [
        {
          "code": "3605091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TPR 3.2/3.9X450 1420-0065S",
      "code_information": [
        {
          "code": "3605102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 858.197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNAL #6 14\\\" 040-365",
      "code_information": [
        {
          "code": "3605111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1245,
          "minimum": 261.45,
          "maximum": 911.589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 838.6619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EXT 1.2 MICRON FILTER",
      "code_information": [
        {
          "code": "3605116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO ST 90 AR-4068-90",
      "code_information": [
        {
          "code": "3605127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1034.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP EXT 6.2/3.2",
      "code_information": [
        {
          "code": "3605137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1333.7755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP NORM 4.9/2.2",
      "code_information": [
        {
          "code": "3605138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1333.7755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-HIP S5/38.5X105 7000-6605",
      "code_information": [
        {
          "code": "3699561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7456,
          "minimum": 1565.76,
          "maximum": 5459.2832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5022.5405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-JEWETT TLSO S/M REGULAR",
      "code_information": [
        {
          "code": "3699634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.4759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 15M",
      "code_information": [
        {
          "code": "3700007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3512,
          "minimum": 737.52,
          "maximum": 2571.4864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2365.7675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORPREP    260700",
      "code_information": [
        {
          "code": "3800580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.3757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORQUE-DEVICE           46-550",
      "code_information": [
        {
          "code": "3801395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-18G BARE NEEDLE 78060",
      "code_information": [
        {
          "code": "3820010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1115,
          "minimum": 234.15,
          "maximum": 816.403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 751.0908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 18X6     618735",
      "code_information": [
        {
          "code": "3820055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2797,
          "minimum": 587.37,
          "maximum": 2047.9634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1884.1263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 22X6     618743",
      "code_information": [
        {
          "code": "3820057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1885.4736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 25x6 611771",
      "code_information": [
        {
          "code": "3820062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3718,
          "minimum": 780.78,
          "maximum": 2722.3196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2504.534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BACKSTOP                MBS100",
      "code_information": [
        {
          "code": "3820086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.3207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-SURGICAL PACEDISP 5833SL",
      "code_information": [
        {
          "code": "3820163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 357,
          "minimum": 74.97,
          "maximum": 261.3954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 240.4838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING DISP         6651",
      "code_information": [
        {
          "code": "3820222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACEMAKER           6697",
      "code_information": [
        {
          "code": "3820223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING         FL-601-97",
      "code_information": [
        {
          "code": "3820226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD                  6623",
      "code_information": [
        {
          "code": "3820227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 235.0948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON WEDGE PRESSURE",
      "code_information": [
        {
          "code": "3820550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 647.3527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ATH-GUIDE 8F",
      "code_information": [
        {
          "code": "3821029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUIDE 6FR",
      "code_information": [
        {
          "code": "3821056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUIDE 6F",
      "code_information": [
        {
          "code": "3821057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUID 7FR",
      "code_information": [
        {
          "code": "3821245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.9392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 162,
          "minimum": 34.02,
          "maximum": 118.6164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.1271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.9392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOGRAM,BALLOON     6215",
      "code_information": [
        {
          "code": "3823025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.2635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION      04527-05",
      "code_information": [
        {
          "code": "3823418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 581,
          "minimum": 122.01,
          "maximum": 425.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 391.3755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-COPILOT         1003331",
      "code_information": [
        {
          "code": "3823422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 282.2485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP    XX*RF0xx",
      "code_information": [
        {
          "code": "3823429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 282.2485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE           MAP500",
      "code_information": [
        {
          "code": "3823431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-SAFEGUARD PRES  D82000D",
      "code_information": [
        {
          "code": "3823437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 738,
          "minimum": 154.98,
          "maximum": 540.3636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 497.1345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP 24CM   3524",
      "code_information": [
        {
          "code": "3823443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL 5FR 20CM G00972",
      "code_information": [
        {
          "code": "3823451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-STATLOCK   D684000472",
      "code_information": [
        {
          "code": "3823520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 270,
          "minimum": 56.7,
          "maximum": 197.694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.8785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENVELOPE-TYRX ABSORB CMRM6133",
      "code_information": [
        {
          "code": "3823584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3401.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAGONFLY OPTIS    C40864x",
      "code_information": [
        {
          "code": "3824115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3181,
          "minimum": 668.01,
          "maximum": 2329.1282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2142.7979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION          LNQTOOL",
      "code_information": [
        {
          "code": "3824170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION  D884-00-0019-13",
      "code_information": [
        {
          "code": "3824174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 792.8554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION  D884-00-0019-17",
      "code_information": [
        {
          "code": "3824175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 792.8554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACCESSORY     518-027",
      "code_information": [
        {
          "code": "3824178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1514,
          "minimum": 317.94,
          "maximum": 1108.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1019.8667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INJECTION     ART700SYR",
      "code_information": [
        {
          "code": "3824179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.8216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC 17L         6056M",
      "code_information": [
        {
          "code": "3824181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD CAP           5867-3M",
      "code_information": [
        {
          "code": "3824183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 344,
          "minimum": 72.24,
          "maximum": 251.8768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.7267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INTELL SYR   K05-00626F",
      "code_information": [
        {
          "code": "3824184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURGIFLO 8ML          2991",
      "code_information": [
        {
          "code": "3824205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1355,
          "minimum": 284.55,
          "maximum": 992.131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 912.7605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET             6057-45",
      "code_information": [
        {
          "code": "3824219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SERVICE WRENCH       5873W",
      "code_information": [
        {
          "code": "3824221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 526,
          "minimum": 110.46,
          "maximum": 385.1372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 354.3262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PINCH-ON-TOOL         6056",
      "code_information": [
        {
          "code": "3824225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET PACEMAKER   60xx-xx",
      "code_information": [
        {
          "code": "3824226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET             6091-53",
      "code_information": [
        {
          "code": "3824228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.3244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE  23548-001",
      "code_information": [
        {
          "code": "3824246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 927,
          "minimum": 194.67,
          "maximum": 678.7494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 624.4494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-THREE PORT 203BN-R",
      "code_information": [
        {
          "code": "3824285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MULTIPAC-4FR SHEATH   538-493P",
      "code_information": [
        {
          "code": "3824294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 280.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-18G BARE          78050",
      "code_information": [
        {
          "code": "3824350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1037,
          "minimum": 217.77,
          "maximum": 759.2914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 698.5481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSEPTAL BRK-1 407201",
      "code_information": [
        {
          "code": "3824358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1765,
          "minimum": 370.65,
          "maximum": 1292.333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1188.9464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSEPTAL       G02364",
      "code_information": [
        {
          "code": "3824360",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1241,
          "minimum": 260.61,
          "maximum": 908.6602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 835.9674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV FINAL    DS2C01",
      "code_information": [
        {
          "code": "3824368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.7529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER  DS2A003",
      "code_information": [
        {
          "code": "3824369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 409,
          "minimum": 85.89,
          "maximum": 299.4698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 275.5122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-D-STAT DRY CLEAR    3005",
      "code_information": [
        {
          "code": "3824415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DEFIBRILLATOR        6998",
      "code_information": [
        {
          "code": "3824426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 557.087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-PIN DF-1             6996",
      "code_information": [
        {
          "code": "3824428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 235.0948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING SMARTABLATE  SAT001",
      "code_information": [
        {
          "code": "3824441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 647.3527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICROPUNCTURE     S-MAK401",
      "code_information": [
        {
          "code": "3824445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 427,
          "minimum": 89.67,
          "maximum": 312.6494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.6374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GLIDE 6FR   RM*BF6M10MA",
      "code_information": [
        {
          "code": "3824476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 456,
          "minimum": 95.76,
          "maximum": 333.8832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 307.1725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-SAFE ALL SZS CLS-10xx.x",
      "code_information": [
        {
          "code": "3824605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INTRODUCER     CLS-250x",
      "code_information": [
        {
          "code": "3824621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 359,
          "minimum": 75.39,
          "maximum": 262.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J426H",
      "code_information": [
        {
          "code": "3824635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-INJECTOR 150 C853-6150",
      "code_information": [
        {
          "code": "3824642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.2789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 27\\\"    J427H",
      "code_information": [
        {
          "code": "3824649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.7647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMAX ADHESIVE MAXA",
      "code_information": [
        {
          "code": "3824663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 162.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-STATLOCK PSI 0684-00-'s",
      "code_information": [
        {
          "code": "3824681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 317,
          "minimum": 66.57,
          "maximum": 232.1074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 213.5388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXR35",
      "code_information": [
        {
          "code": "3824705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-UNIVERSAL      6232ADJ",
      "code_information": [
        {
          "code": "3824709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-UNIVERSAL      6230UNI",
      "code_information": [
        {
          "code": "3824710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-CONNECTOR PSA EX3151",
      "code_information": [
        {
          "code": "3824711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1045,
          "minimum": 219.45,
          "maximum": 765.149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.9371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STERILE 30CM     406500",
      "code_information": [
        {
          "code": "3824713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRT XSOFT 59CM 5005",
      "code_information": [
        {
          "code": "3824883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-LONG SOFT 59CM 5014",
      "code_information": [
        {
          "code": "3824884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.1535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-RUST            6054-58",
      "code_information": [
        {
          "code": "3824889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.8861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CONTROL 20ML    CCS320",
      "code_information": [
        {
          "code": "3824955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLUID WASTE    64000936",
      "code_information": [
        {
          "code": "3824996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.74,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-FLEXTEND FIXATION    6616",
      "code_information": [
        {
          "code": "3825028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-CONTRAST        HPF480K",
      "code_information": [
        {
          "code": "3825032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PASSAGE HEMOSTAS  MAP112",
      "code_information": [
        {
          "code": "3825048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 133.3776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             6628",
      "code_information": [
        {
          "code": "3825085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.4648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-GLIDEWIRE INSERT   MAP550",
      "code_information": [
        {
          "code": "3825086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HIGH PRES 20\\\"   HPF200E",
      "code_information": [
        {
          "code": "3825097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDAL MICROPUNCTURE G02972",
      "code_information": [
        {
          "code": "3825123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 717,
          "minimum": 150.57,
          "maximum": 524.9874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.9884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-PACEMAKER ALL",
      "code_information": [
        {
          "code": "3825190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 402.8272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.0X150MM 390142",
      "code_information": [
        {
          "code": "3900001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150MM SS 390162",
      "code_information": [
        {
          "code": "3900002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X55X32MM 608455",
      "code_information": [
        {
          "code": "3900059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X60X16MM 608260",
      "code_information": [
        {
          "code": "3900060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X60X32MM 608460",
      "code_information": [
        {
          "code": "3900061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X65X16MM 608265",
      "code_information": [
        {
          "code": "3900062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X65X32MM 608465",
      "code_information": [
        {
          "code": "3900063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X70X16MM 608270",
      "code_information": [
        {
          "code": "3900064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X70X32MM 608470",
      "code_information": [
        {
          "code": "3900065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X75X16MM 608275",
      "code_information": [
        {
          "code": "3900066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X75X32MM 608475",
      "code_information": [
        {
          "code": "3900067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X80X16MM 608280",
      "code_information": [
        {
          "code": "3900068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X80X32MM 608480",
      "code_information": [
        {
          "code": "3900069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X85X16MM 608285",
      "code_information": [
        {
          "code": "3900070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X85X32MM 608485",
      "code_information": [
        {
          "code": "3900071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X90X16MM 608290",
      "code_information": [
        {
          "code": "3900072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X90X32MM 608490",
      "code_information": [
        {
          "code": "3900073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X95X16MM 608295",
      "code_information": [
        {
          "code": "3900074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X95X32MM 608495",
      "code_information": [
        {
          "code": "3900075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X20MM 608020",
      "code_information": [
        {
          "code": "3900076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X30MM 608030",
      "code_information": [
        {
          "code": "3900077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X35MM 608035",
      "code_information": [
        {
          "code": "3900078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X45MM 608045",
      "code_information": [
        {
          "code": "3900079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X50MM 608050",
      "code_information": [
        {
          "code": "3900080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X55MM 608055",
      "code_information": [
        {
          "code": "3900081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X65MM 608065",
      "code_information": [
        {
          "code": "3900082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 828.5575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X75MM 608075",
      "code_information": [
        {
          "code": "3900083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X80MM 608080",
      "code_information": [
        {
          "code": "3900084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X90MM 608090",
      "code_information": [
        {
          "code": "3900085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X95MM 608095",
      "code_information": [
        {
          "code": "3900086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 1.7MM 59-17049E",
      "code_information": [
        {
          "code": "3900087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 2.3MM 59-23049E",
      "code_information": [
        {
          "code": "3900088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 2.3MM 619915",
      "code_information": [
        {
          "code": "3900089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X120MM 5079-6-120",
      "code_information": [
        {
          "code": "3900090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X150MM 5079-6-150",
      "code_information": [
        {
          "code": "3900091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X30MM 5079-6-030",
      "code_information": [
        {
          "code": "3900092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X40MM 5079-6-040",
      "code_information": [
        {
          "code": "3900093",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X50MM 5079-6-050",
      "code_information": [
        {
          "code": "3900094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X60MM 5079-6-060",
      "code_information": [
        {
          "code": "3900095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X90MM 5079-6-090",
      "code_information": [
        {
          "code": "3900096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 5X200/60TH 5018-6-200",
      "code_information": [
        {
          "code": "3900097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2X36/15TH 5065-3-615",
      "code_information": [
        {
          "code": "3900098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2X45/20TH 5065-4-520",
      "code_information": [
        {
          "code": "3900099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.5255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "PIN-APEX 2X90/15TH 5065-9-015",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 947.4668,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 272.58,
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    {
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          "type": "LOCAL"
        },
        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    {
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          "type": "LOCAL"
        },
        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-NLOCK FT 2.7X32MM 657132",
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        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
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        {
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          ]
        }
      ],
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        {
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        }
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
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            }
          ]
        }
      ],
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    },
    {
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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        }
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            }
          ]
        }
      ],
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    },
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        {
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        }
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            }
          ]
        }
      ],
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    },
    {
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        {
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        }
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          ]
        }
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        {
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      ],
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    },
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        {
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          ]
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            }
          ]
        }
      ],
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    },
    {
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        {
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          ]
        }
      ],
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    },
    {
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        {
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            }
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      ],
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    },
    {
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        },
        {
          "code": "0270",
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          ]
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    {
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        {
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        {
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    {
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        {
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    {
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      ],
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    },
    {
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        {
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
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        }
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            }
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        }
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    },
    {
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        }
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      ],
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    {
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    {
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        {
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      ],
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      ],
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        {
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    },
    {
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        {
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      ],
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      ],
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    },
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        {
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      ],
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    },
    {
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        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1174.1266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 4.0X28MM 604628",
      "code_information": [
        {
          "code": "3900211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1786,
          "minimum": 375.06,
          "maximum": 1307.7092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1203.0925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-ANGLE 11MM 4922-2-120",
      "code_information": [
        {
          "code": "3900212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1006,
          "minimum": 211.26,
          "maximum": 736.5932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 677.6657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 4.0X95MM 661095",
      "code_information": [
        {
          "code": "3900214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.2712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X14MM 661114",
      "code_information": [
        {
          "code": "3900215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.2712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X16MM 661116",
      "code_information": [
        {
          "code": "3900216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.2712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X18MM 661118",
      "code_information": [
        {
          "code": "3900217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.2712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X20MM 661120",
      "code_information": [
        {
          "code": "3900218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.2712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X95MM 661195",
      "code_information": [
        {
          "code": "3900220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X20MM 601620",
      "code_information": [
        {
          "code": "3900221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X22MM 601622",
      "code_information": [
        {
          "code": "3900222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X24MM 601624",
      "code_information": [
        {
          "code": "3900223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X28MM 601628",
      "code_information": [
        {
          "code": "3900224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X34MM 601634",
      "code_information": [
        {
          "code": "3900225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X36MM 601636",
      "code_information": [
        {
          "code": "3900226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X44MM 601644",
      "code_information": [
        {
          "code": "3900227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X6MM 662506",
      "code_information": [
        {
          "code": "3900239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X7MM 662507",
      "code_information": [
        {
          "code": "3900240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X9MM 662509",
      "code_information": [
        {
          "code": "3900241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X14MM 663714",
      "code_information": [
        {
          "code": "3900242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X15MM 663715",
      "code_information": [
        {
          "code": "3900243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X18MM 663718",
      "code_information": [
        {
          "code": "3900244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X20MM 663720",
      "code_information": [
        {
          "code": "3900245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X22MM 663722",
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        {
          "code": "3900246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X24MM 663724",
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        {
          "code": "3900247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X26MM 663726",
      "code_information": [
        {
          "code": "3900248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X30MM 656030",
      "code_information": [
        {
          "code": "3900263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 702.5898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X32MM 656032",
      "code_information": [
        {
          "code": "3900264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 702.5898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X34MM 656034",
      "code_information": [
        {
          "code": "3900265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 702.5898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X36MM 656036",
      "code_information": [
        {
          "code": "3900266",
          "type": "LOCAL"
        },
        {
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          ]
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    {
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        {
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    {
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        {
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    {
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        {
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        {
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          ]
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        {
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    {
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          ]
        }
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    {
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    {
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          ]
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    {
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        {
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        {
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    {
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        {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X13MM 656013",
      "code_information": [
        {
          "code": "3900315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 796.8972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X15MM 656015",
      "code_information": [
        {
          "code": "3900316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 796.8972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X40MM 656040",
      "code_information": [
        {
          "code": "3900317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 796.8972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X42MM 656042",
      "code_information": [
        {
          "code": "3900318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 796.8972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X44MM 656044",
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        {
          "code": "3900319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 796.8972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X46MM 656046",
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        {
          "code": "3900320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 248.43,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 796.8972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X48MM 656048",
      "code_information": [
        {
          "code": "3900321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 796.8972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X50MM 656050",
      "code_information": [
        {
          "code": "3900322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 277,
          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.5938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X55MM 656055",
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        {
          "code": "3900323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2855,
          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1923.1965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X60MM 656060",
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        {
          "code": "3900324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1923.1965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X65MM 656065",
      "code_information": [
        {
          "code": "3900325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 599.55,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1923.1965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X70MM 656070",
      "code_information": [
        {
          "code": "3900326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3218,
          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2167.722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X7MM 656007",
      "code_information": [
        {
          "code": "3900327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2167.722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X9MM 656009",
      "code_information": [
        {
          "code": "3900328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2167.722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X11MM 656311",
      "code_information": [
        {
          "code": "3900329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1930,
          "minimum": 405.3,
          "maximum": 1413.146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1300.0943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X13MM 656313",
      "code_information": [
        {
          "code": "3900330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 405.3,
          "maximum": 1413.146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1300.0943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X15MM 656315",
      "code_information": [
        {
          "code": "3900331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2080,
          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1401.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X42MM 656342",
      "code_information": [
        {
          "code": "3900332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1401.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X44MM 656344",
      "code_information": [
        {
          "code": "3900333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1401.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X46MM 656346",
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        {
          "code": "3900334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 436.8,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1401.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X48MM 656348",
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        {
          "code": "3900335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1401.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X55MM 656355",
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        {
          "code": "3900336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 586.32,
          "maximum": 2044.3024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1880.7582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X60MM 656360",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X65MM 656365",
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        {
          "code": "3900338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 586.32,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X7MM 656307",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 467.67,
          "maximum": 1630.6094,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1500.1606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X9MM 656309",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 620.76,
          "maximum": 2164.3832,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1991.2325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X18MM 657018",
      "code_information": [
        {
          "code": "3900343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3646,
          "minimum": 765.66,
          "maximum": 2669.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2456.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X22MM 657022",
      "code_information": [
        {
          "code": "3900344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4336,
          "minimum": 910.56,
          "maximum": 3174.8192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2920.8337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X26MM 657026",
      "code_information": [
        {
          "code": "3900345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2956,
          "minimum": 620.76,
          "maximum": 2164.3832,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1991.2325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X28MM 657028",
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        {
          "code": "3900346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 467.67,
          "maximum": 1630.6094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X30MM 657030",
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        {
          "code": "3900347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 620.76,
          "maximum": 2164.3832,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1991.2325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X32MM 657032",
      "code_information": [
        {
          "code": "3900348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 620.76,
          "maximum": 2164.3832,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1991.2325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X34MM 657034",
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        {
          "code": "3900349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 620.76,
          "maximum": 2164.3832,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1991.2325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X36MM 657036",
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        {
          "code": "3900350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3646,
          "minimum": 765.66,
          "maximum": 2669.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2456.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X38MM 657038",
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        {
          "code": "3900351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 765.66,
          "maximum": 2669.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2456.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X40MM 657040",
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        {
          "code": "3900352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 765.66,
          "maximum": 2669.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2456.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X42MM 657042",
      "code_information": [
        {
          "code": "3900353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 910.56,
          "maximum": 3174.8192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2920.8337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X44MM 657044",
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        {
          "code": "3900354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 3174.8192,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2920.8337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X46MM 657046",
      "code_information": [
        {
          "code": "3900355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2920.8337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X48MM 657048",
      "code_information": [
        {
          "code": "3900356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 2195,
          "minimum": 460.95,
          "maximum": 1607.179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1478.6047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X50MM 657050",
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        {
          "code": "3900357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2077,
          "minimum": 436.17,
          "maximum": 1520.7794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1399.117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X60MM 657060",
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        {
          "code": "3900359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1116.78,
          "maximum": 3893.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3582.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X65MM 657065",
      "code_information": [
        {
          "code": "3900360",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1116.78,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3582.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X70MM 657070",
      "code_information": [
        {
          "code": "3900361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3582.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X8MM 657008",
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        {
          "code": "3900362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 3893.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3582.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X65MM 657365",
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        {
          "code": "3900363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5577,
          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3756.801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X70MM 657370",
      "code_information": [
        {
          "code": "3900364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3756.801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-WIRE K 2.0X200MM 705135",
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        {
          "code": "3900365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1171.17,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3756.801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEED 2.0X30MM AO 703892",
      "code_information": [
        {
          "code": "3900366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 73.71,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 236.442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEED 2.6X30MM AO 703894",
      "code_information": [
        {
          "code": "3900367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 81.48,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-10101",
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        {
          "code": "3900375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5775,
          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3890.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-10102",
      "code_information": [
        {
          "code": "3900376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3890.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/1.7MM 57-05210",
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        {
          "code": "3900377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1212.75,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3890.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/2.3 57-10161",
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        {
          "code": "3900378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1212.75,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3890.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 10H/2.3MM 57-13442",
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        {
          "code": "3900379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3890.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/2.3MM 57-13402",
      "code_information": [
        {
          "code": "3900380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3890.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-13420",
      "code_information": [
        {
          "code": "3900384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6482,
          "minimum": 1361.22,
          "maximum": 4746.1204,
          "payers_information": [
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 16H/2.3MM 57-10116",
      "code_information": [
        {
          "code": "3900437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4044,
          "minimum": 849.24,
          "maximum": 2961.0168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2724.1355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3D 2X2+2H 57-10197",
      "code_information": [
        {
          "code": "3900438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4044,
          "minimum": 849.24,
          "maximum": 2961.0168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2724.1355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3D 4X2H 57-10195",
      "code_information": [
        {
          "code": "3900439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4044,
          "minimum": 849.24,
          "maximum": 2961.0168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2724.1355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/2.3MM 57-10191",
      "code_information": [
        {
          "code": "3900440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4044,
          "minimum": 849.24,
          "maximum": 2961.0168,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2724.1355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/2.3MM 57-10192",
      "code_information": [
        {
          "code": "3900441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 13H/2.3 57-10179",
      "code_information": [
        {
          "code": "3900442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 10H/2X54MM 629610",
      "code_information": [
        {
          "code": "3900443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 4H/2X22MM 629604",
      "code_information": [
        {
          "code": "3900444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 5H 629505",
      "code_information": [
        {
          "code": "3900445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3362.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-PIN TO ROD 4922-1-020",
      "code_information": [
        {
          "code": "3900446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5307,
          "minimum": 1114.47,
          "maximum": 3885.7854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3574.9226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 10H/2.4X66MM 629670",
      "code_information": [
        {
          "code": "3900447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2511.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 20H/2X108MM 629620",
      "code_information": [
        {
          "code": "3900448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2511.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 4H/2.4X26MM 629664",
      "code_information": [
        {
          "code": "3900449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2511.2703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 6H/2.4X40MM 629666",
      "code_information": [
        {
          "code": "3900450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 8H/2.4X53MM 629668",
      "code_information": [
        {
          "code": "3900451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-PIN TO ROD 4922-1-030",
      "code_information": [
        {
          "code": "3900452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-ROD TO ROD 4922-1-010",
      "code_information": [
        {
          "code": "3900453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 20H/2.4X132MM 629680",
      "code_information": [
        {
          "code": "3900454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.0006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-PIN 5H 4922-2-020",
      "code_information": [
        {
          "code": "3900455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3362.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3MM 57-10185",
      "code_information": [
        {
          "code": "3900456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3362.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3MM 57-13185",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3362.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 16H/1.7MM 57-10316",
      "code_information": [
        {
          "code": "3900458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3362.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2+2H/1.7 57-10397",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1180.83,
          "maximum": 4117.1606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3787.7878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/1.7 57-10390",
      "code_information": [
        {
          "code": "3900460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3362.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/2.3 57-15390",
      "code_information": [
        {
          "code": "3900461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3362.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 9H/1.7MM 57-10379",
      "code_information": [
        {
          "code": "3900474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 14H/167MM",
      "code_information": [
        {
          "code": "3900475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 16H/191MM",
      "code_information": [
        {
          "code": "3900476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 10H/2X57MM 629630",
      "code_information": [
        {
          "code": "3900477",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 6H/2X34MM 629626",
      "code_information": [
        {
          "code": "3900478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 8H/2X46MM 629628",
      "code_information": [
        {
          "code": "3900479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2X23MM 629624",
      "code_information": [
        {
          "code": "3900480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 10H 629560",
      "code_information": [
        {
          "code": "3900481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 9H 629559",
      "code_information": [
        {
          "code": "3900482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 10H 629510",
      "code_information": [
        {
          "code": "3900483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 8H 629548",
      "code_information": [
        {
          "code": "3900484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR LONG LT 54-25405",
      "code_information": [
        {
          "code": "3900499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR LONG RT 54-25404",
      "code_information": [
        {
          "code": "3900500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR SHORT LT 54-25403",
      "code_information": [
        {
          "code": "3900501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR SHORT RT 54-25402",
      "code_information": [
        {
          "code": "3900502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.4X69MM 629690",
      "code_information": [
        {
          "code": "3900503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2.4X28 629684",
      "code_information": [
        {
          "code": "3900504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2.4X41MM 629686",
      "code_information": [
        {
          "code": "3900505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.4X56MM 629688",
      "code_information": [
        {
          "code": "3900506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/150MM 629512",
      "code_information": [
        {
          "code": "3900507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/174MM 629514",
      "code_information": [
        {
          "code": "3900508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 11H 629561",
      "code_information": [
        {
          "code": "3900509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 12H 629562",
      "code_information": [
        {
          "code": "3900510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 14H 629564",
      "code_information": [
        {
          "code": "3900511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.4X80 629710",
      "code_information": [
        {
          "code": "3900512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X5H/2.7X47MM 629784",
      "code_information": [
        {
          "code": "3900530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 5X10H/2.7X87MM 629787",
      "code_information": [
        {
          "code": "3900531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TRI 10H/2.4X81MM 629791",
      "code_information": [
        {
          "code": "3900532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-Y 10H/2.4X81MM 629790",
      "code_information": [
        {
          "code": "3900533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 12H/2.7X108 629752",
      "code_information": [
        {
          "code": "3900534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 14H/2.7X125 629754",
      "code_information": [
        {
          "code": "3900535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL STD LT 54-25291",
      "code_information": [
        {
          "code": "3900536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL STD RT 54-25290",
      "code_information": [
        {
          "code": "3900537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL WIDE LT 54-25293",
      "code_information": [
        {
          "code": "3900538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL WIDE RT 54-25292",
      "code_information": [
        {
          "code": "3900539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/LT 628303",
      "code_information": [
        {
          "code": "3900540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/RT 629323",
      "code_information": [
        {
          "code": "3900541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/RT/629263",
      "code_information": [
        {
          "code": "3900542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/84MM/LT 629203",
      "code_information": [
        {
          "code": "3900543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/84MM/RT 629223",
      "code_information": [
        {
          "code": "3900544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 3H 629283",
      "code_information": [
        {
          "code": "3900545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 10H/2.7X92MM 629788",
      "code_information": [
        {
          "code": "3900546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TRI 10H/2.7X92MM 629789",
      "code_information": [
        {
          "code": "3900547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/5X79MM 627534",
      "code_information": [
        {
          "code": "3900548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DEC 6H/75MM/LT 628006",
      "code_information": [
        {
          "code": "3900549",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/105MM/LT 629244",
      "code_information": [
        {
          "code": "3900550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/109MM/LT 629204",
      "code_information": [
        {
          "code": "3900551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/109MM/RT 629204",
      "code_information": [
        {
          "code": "3900552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/LT 629304",
      "code_information": [
        {
          "code": "3900553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/RT 629324",
      "code_information": [
        {
          "code": "3900554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 933.6429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/128MM/RT 629266",
      "code_information": [
        {
          "code": "3900555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/132MM /RT 629226",
      "code_information": [
        {
          "code": "3900556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/132MM/LT 629206",
      "code_information": [
        {
          "code": "3900557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/LT 629306",
      "code_information": [
        {
          "code": "3900558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/RT 629326",
      "code_information": [
        {
          "code": "3900559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 4H 629284",
      "code_information": [
        {
          "code": "3900560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 6H 629286",
      "code_information": [
        {
          "code": "3900561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-OLE 6H/113MM/LT 629346",
      "code_information": [
        {
          "code": "3900562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/71MM/RT 627734",
      "code_information": [
        {
          "code": "3900563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 12H/76MM/RT 54-25385",
      "code_information": [
        {
          "code": "3900564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 14H/76MM/LT 54-25377",
      "code_information": [
        {
          "code": "3900565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 14H/76MM/RT 54-25387",
      "code_information": [
        {
          "code": "3900566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG 54-25296",
      "code_information": [
        {
          "code": "3900567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG 54-25297",
      "code_information": [
        {
          "code": "3900568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG LT 54-25295",
      "code_information": [
        {
          "code": "3900569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG RT 54-25294",
      "code_information": [
        {
          "code": "3900570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 5H/84MM/LT 627705",
      "code_information": [
        {
          "code": "3900571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 5H/84MM/RT 627735",
      "code_information": [
        {
          "code": "3900572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 5H/5X97MM 627535",
      "code_information": [
        {
          "code": "3900573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/5X115MM 627536",
      "code_information": [
        {
          "code": "3900574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/5X119MM 627566",
      "code_information": [
        {
          "code": "3900575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 6H/97MM/LT 627706",
      "code_information": [
        {
          "code": "3900576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/97MM/LT 627404",
      "code_information": [
        {
          "code": "3900577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/97MM/RT 627434",
      "code_information": [
        {
          "code": "3900578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 937.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/123MM/LT 627708",
      "code_information": [
        {
          "code": "3900579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 6H 628406",
      "code_information": [
        {
          "code": "3900580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 7 H 628407",
      "code_information": [
        {
          "code": "3900581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 8 H 628408",
      "code_information": [
        {
          "code": "3900582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 10H 628310",
      "code_information": [
        {
          "code": "3900583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 7 H 628307",
      "code_information": [
        {
          "code": "3900584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 8 H 628308",
      "code_information": [
        {
          "code": "3900585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 10H/120MM/RT 628130",
      "code_information": [
        {
          "code": "3900586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 8H/97MM/LT 628108",
      "code_information": [
        {
          "code": "3900587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 8H/97MM/RT 628128",
      "code_information": [
        {
          "code": "3900588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 11H/5X209MM 627571",
      "code_information": [
        {
          "code": "3900590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1084.5346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/5X223MM 627542",
      "code_information": [
        {
          "code": "3900591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1084.5346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/5X227MM 627572",
      "code_information": [
        {
          "code": "3900592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1084.5346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 8H/5X155MM 627568",
      "code_information": [
        {
          "code": "3900593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1516.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 9H/5X173MM 627569",
      "code_information": [
        {
          "code": "3900594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1516.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/102MM RT 627484",
      "code_information": [
        {
          "code": "3900595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1516.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/102MM/LT 627454",
      "code_information": [
        {
          "code": "3900596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1516.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 13H/5X245MM 627573",
      "code_information": [
        {
          "code": "3900597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1770,
          "minimum": 371.7,
          "maximum": 1295.994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1192.3145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/5X259MM 627544",
      "code_information": [
        {
          "code": "3900598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2855,
          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1923.1965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/5X263MM 627574",
      "code_information": [
        {
          "code": "3900599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1375.5402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 6H/127MM/LT 627456",
      "code_information": [
        {
          "code": "3900600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1375.5402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/121MM/LT 627304",
      "code_information": [
        {
          "code": "3900601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1375.5402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/153MM/RT 627488",
      "code_information": [
        {
          "code": "3900602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1375.5402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/178MM/LT 627460",
      "code_information": [
        {
          "code": "3900603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1883.4527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 6H/RT 628166",
      "code_information": [
        {
          "code": "3900608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 8H/LT 628148",
      "code_information": [
        {
          "code": "3900609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 8H/RT 628168",
      "code_information": [
        {
          "code": "3900610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/199MM/LT 627310",
      "code_information": [
        {
          "code": "3900611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/199MM/RT 627340",
      "code_information": [
        {
          "code": "3900612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 12H/225MM/LT 627312",
      "code_information": [
        {
          "code": "3900613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 12H/225MM/RT 627342",
      "code_information": [
        {
          "code": "3900614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/139MM 629388",
      "code_information": [
        {
          "code": "3900615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/150MM/LT 629248",
      "code_information": [
        {
          "code": "3900616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1636.2327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/156MM/LT 629208",
      "code_information": [
        {
          "code": "3900617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/156MM/RT 629228",
      "code_information": [
        {
          "code": "3900618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/LT 629308",
      "code_information": [
        {
          "code": "3900619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/RT 629328",
      "code_information": [
        {
          "code": "3900620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 8H 629288",
      "code_information": [
        {
          "code": "3900621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-OLE 8H/137MM/LT 629348",
      "code_information": [
        {
          "code": "3900622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 14H/251MM/LT 627314",
      "code_information": [
        {
          "code": "3900623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 14H/251MM/RT 627344",
      "code_information": [
        {
          "code": "3900624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 7H/122/LT 628207",
      "code_information": [
        {
          "code": "3900625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 7H/122/RT 628227",
      "code_information": [
        {
          "code": "3900626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1289.99,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 10H/176MM/RT 627240",
      "code_information": [
        {
          "code": "3900627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1883.4527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/151MM/LT 627208",
      "code_information": [
        {
          "code": "3900628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1883.4527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 4H/130MM/RT 627634",
      "code_information": [
        {
          "code": "3900630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1883.4527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 14H/310MM/LT 627614",
      "code_information": [
        {
          "code": "3900636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 411,
          "minimum": 86.31,
          "maximum": 300.9342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 276.8595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 14H/310MM/RT 627644",
      "code_information": [
        {
          "code": "3900637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 411,
          "minimum": 86.31,
          "maximum": 300.9342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 276.8595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 16H/343MM/RT 627646",
      "code_information": [
        {
          "code": "3900638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 742.3336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-GAIT UNIVERSAL M2616D01",
      "code_information": [
        {
          "code": "4432470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.9943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IC SILVER 16FR 30CC SI16",
      "code_information": [
        {
          "code": "4433340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.9392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN FOLEY 12 FR 5CC",
      "code_information": [
        {
          "code": "4435701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.1764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENIPUNCTURE STIK-GUARD",
      "code_information": [
        {
          "code": "4445500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.6053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYMEM 3X1",
      "code_information": [
        {
          "code": "4452250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.0911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEN 4X12 1/2 5124",
      "code_information": [
        {
          "code": "4454125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EXT MIC-KEY 0121-24",
      "code_information": [
        {
          "code": "4455449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-DISP SLIPTIP DX",
      "code_information": [
        {
          "code": "4458390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-EBUS          MAJ-1351",
      "code_information": [
        {
          "code": "4820147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RAPID REFILL INJECTION",
      "code_information": [
        {
          "code": "4820306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 335,
          "minimum": 70.35,
          "maximum": 245.287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 225.664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RX DELIVERY 10FR",
      "code_information": [
        {
          "code": "4820316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHOTRIPTER RX",
      "code_information": [
        {
          "code": "4820525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.2443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL PULM 0 12/120",
      "code_information": [
        {
          "code": "4820546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1671,
          "minimum": 350.91,
          "maximum": 1223.5062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1125.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CLEANING          000336",
      "code_information": [
        {
          "code": "4820730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.5312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CLEANING 1-1.5MMX1650MM",
      "code_information": [
        {
          "code": "4820735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 132,
          "minimum": 27.72,
          "maximum": 96.6504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.9184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY BARD     000107",
      "code_information": [
        {
          "code": "4820950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.3358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY RX",
      "code_information": [
        {
          "code": "4821045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-MICRO BIOLOGY        130",
      "code_information": [
        {
          "code": "4821100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 183.2257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G TUBE ALL SIZES",
      "code_information": [
        {
          "code": "4821257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1029,
          "minimum": 216.09,
          "maximum": 753.4338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 693.1591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TAPER TIP RX      4577",
      "code_information": [
        {
          "code": "4821690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 878,
          "minimum": 184.38,
          "maximum": 642.8716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 591.4419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO PH     9012B1011",
      "code_information": [
        {
          "code": "4821720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1311.5459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-TWISTER PLUS 26MM",
      "code_information": [
        {
          "code": "4822220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 503.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTAT RESOLUTION",
      "code_information": [
        {
          "code": "4822320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.7529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LOCKING ERCP RX    4526",
      "code_information": [
        {
          "code": "4822475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.9051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP  RJ4 1333-4",
      "code_information": [
        {
          "code": "4823705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY SUPERTRAX",
      "code_information": [
        {
          "code": "4823755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 503.1971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW DISP 1550-40",
      "code_information": [
        {
          "code": "4823800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 275,
          "minimum": 57.75,
          "maximum": 201.355,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.2466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ANGIOGRAPHIC CATHETER",
      "code_information": [
        {
          "code": "4824510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 864.9332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDER-SPEED SUPERVIEW 7  4225",
      "code_information": [
        {
          "code": "4824650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1655,
          "minimum": 347.55,
          "maximum": 1211.791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1114.8477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-MULTIBITE 240 CM   1012",
      "code_information": [
        {
          "code": "4825400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.7627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-400Y-0423",
      "code_information": [
        {
          "code": "4825501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR   NM-400L-0525",
      "code_information": [
        {
          "code": "4825519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GAUGE EBUS",
      "code_information": [
        {
          "code": "4825530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 572.5804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GAUGE EBUS",
      "code_information": [
        {
          "code": "4825535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 774.6676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EXCELON  19G",
      "code_information": [
        {
          "code": "4825654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-NEEDLE RX F/G",
      "code_information": [
        {
          "code": "4825690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-WANG              MW319",
      "code_information": [
        {
          "code": "4825700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 580,
          "minimum": 121.8,
          "maximum": 424.676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 390.7019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTION 25GA",
      "code_information": [
        {
          "code": "4825701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 383,
          "minimum": 80.43,
          "maximum": 280.4326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-FOOD BOLUS ROTH   00711155",
      "code_information": [
        {
          "code": "4825703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 915,
          "minimum": 192.15,
          "maximum": 669.963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 616.366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-ROTATING RETRIVAL 00711050",
      "code_information": [
        {
          "code": "4825705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 608.9561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 1.5MM 4.5FR 150CM",
      "code_information": [
        {
          "code": "4825995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1055.5688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD 7 FR           6007",
      "code_information": [
        {
          "code": "4826050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1249,
          "minimum": 262.29,
          "maximum": 914.5178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 841.3564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-CATHETER MANOSHIELD",
      "code_information": [
        {
          "code": "4826655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL STD 240CM      6232",
      "code_information": [
        {
          "code": "4827202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-DISP HEXAGON CAPTIVATOR",
      "code_information": [
        {
          "code": "4827315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-POLYP 00711099",
      "code_information": [
        {
          "code": "4828705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 170,
          "minimum": 35.7,
          "maximum": 124.474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.5161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLON DECOMP  CDSG-14-175",
      "code_information": [
        {
          "code": "4829170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1525,
          "minimum": 320.25,
          "maximum": 1116.605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1027.2766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 14FR 0100-14LV",
      "code_information": [
        {
          "code": "4829260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 254.6299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22 FR  0100-22",
      "code_information": [
        {
          "code": "4829300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 24 FR  0100-24",
      "code_information": [
        {
          "code": "4829350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 254.6299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 26 FR  0100-26",
      "code_information": [
        {
          "code": "4829400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.0397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10 FR 30-7361",
      "code_information": [
        {
          "code": "4829700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 290.3319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION ENDOGATOR",
      "code_information": [
        {
          "code": "4829895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.3491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-AQUAPLAST 12X18 3.2MM",
      "code_information": [
        {
          "code": "5699102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 330.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 9X12 MT-APU-12",
      "code_information": [
        {
          "code": "5750063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.0397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-PROBE PROSTATE   613-245",
      "code_information": [
        {
          "code": "5995267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 127.9886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BARD BIOPSY 12G     121210",
      "code_information": [
        {
          "code": "5995268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 437.182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE ENDOCAVITY",
      "code_information": [
        {
          "code": "5995272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 253,
          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.4269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE ULTRA PRO II",
      "code_information": [
        {
          "code": "5995273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ULTRASOUND 12GX12CM",
      "code_information": [
        {
          "code": "5995304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1130.3411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY ALL SZS",
      "code_information": [
        {
          "code": "5995532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 514,
          "minimum": 107.94,
          "maximum": 376.3508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 346.2427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY 14X10",
      "code_information": [
        {
          "code": "5995534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 545,
          "minimum": 114.45,
          "maximum": 399.049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 367.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 14GAX15C",
      "code_information": [
        {
          "code": "5995547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 457,
          "minimum": 95.97,
          "maximum": 334.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 307.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 14GAX11C",
      "code_information": [
        {
          "code": "5995550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 416,
          "minimum": 87.36,
          "maximum": 304.5952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 280.2276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-H/S PROCEDURE     61-5205",
      "code_information": [
        {
          "code": "5995761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 584,
          "minimum": 122.64,
          "maximum": 427.6048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 393.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SERTERA-12GA CORE DEVICE",
      "code_information": [
        {
          "code": "5995763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SERTERA-14GA CORE DEVICE",
      "code_information": [
        {
          "code": "5995764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 563.1497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENCOR BX SCCAN01",
      "code_information": [
        {
          "code": "7295114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.4117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC&RINSE TUBE DS4001",
      "code_information": [
        {
          "code": "7295115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.1592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-ENCOR NEEDLE 7G",
      "code_information": [
        {
          "code": "7295267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.6129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRI SCALPEL/NEEDLE KIT",
      "code_information": [
        {
          "code": "7295418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.1707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-HS TMI1156",
      "code_information": [
        {
          "code": "7295727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE F/MRI SSQK65/115VS",
      "code_information": [
        {
          "code": "7295730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "1100160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYN            ALLSZs",
      "code_information": [
        {
          "code": "1100275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 1385.8012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.1349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC PED 10FR    8010",
      "code_information": [
        {
          "code": "1102034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 12FR PEDS   8012",
      "code_information": [
        {
          "code": "1102046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.7937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK BABY",
      "code_information": [
        {
          "code": "1102135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 426.5287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC 3-LUMEN PWR INJ SAFET",
      "code_information": [
        {
          "code": "1110365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 201.8643,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 512.0829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH LUMEN 4FR    AK-14402",
      "code_information": [
        {
          "code": "1110376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 38.927,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "1113245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 240.2352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS          G04153",
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        {
          "code": "1113258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 465.4557,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 288.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-FOREIGN BODY   FB-5000",
      "code_information": [
        {
          "code": "1115735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 837,
          "minimum": 58.9466,
          "maximum": 607.4109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 558.818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEONATE TUBE RESV",
      "code_information": [
        {
          "code": "1115845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 911.4479,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATHETER CRICOTHYROTOMY",
      "code_information": [
        {
          "code": "1118135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1639,
          "minimum": 31.1416,
          "maximum": 1189.4223,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1094.2685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-HANGING CAST LG 1180LPP",
      "code_information": [
        {
          "code": "1118520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "1118720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 116.781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "1118735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 210,
          "minimum": 71.7916,
          "maximum": 636.7345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "#1855G 5-0 ETHILON PC-1",
      "code_information": [
        {
          "code": "1118792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 49,
          "minimum": 16.7514,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 32.7146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EVAC/DRAIN 1-BTL  62287",
      "code_information": [
        {
          "code": "1118801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 188.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED       8CFN",
      "code_information": [
        {
          "code": "1118955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 339,
          "minimum": 22.8001,
          "maximum": 246.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 226.3313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "1119001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 41,
          "minimum": 14.0165,
          "maximum": 29.7537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 27.3734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "1119800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 48,
          "minimum": 16.4095,
          "maximum": 2677.6215,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 32.0469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-15      G00012",
      "code_information": [
        {
          "code": "1410067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 147.5333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINL 22X20     G03542",
      "code_information": [
        {
          "code": "1410472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 256,
          "minimum": 87.5174,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.9169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CUSTOM WASTE BAG",
      "code_information": [
        {
          "code": "1410792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 124.8494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-INDIGO W/TUBING IAPS2",
      "code_information": [
        {
          "code": "1410803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 825.9455,
          "maximum": 2100.3897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1613.0279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INFUSION MRI          1056",
      "code_information": [
        {
          "code": "1410839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE ADAPTER MRI   1057",
      "code_information": [
        {
          "code": "1410840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 153.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 141.5405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18G 20CM   G01047",
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        {
          "code": "1410918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18-15      G03954",
      "code_information": [
        {
          "code": "1411193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 217,
          "minimum": 74.1847,
          "maximum": 549.4268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.8787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MONOPTY 18X10    121810",
      "code_information": [
        {
          "code": "1411612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 63.9515,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.6285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JAR-COPLIN PP STAIN     S90130",
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        {
          "code": "1411903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION     CID-20-30",
      "code_information": [
        {
          "code": "1412310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 734,
          "minimum": 250.9288,
          "maximum": 631.1735,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 490.0507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE .010-.038   TD01",
      "code_information": [
        {
          "code": "1412325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 87.3077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-STAYFIX SMALL    680-ME",
      "code_information": [
        {
          "code": "1412330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 53.6728,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.8201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL IV 6FR   48-152",
      "code_information": [
        {
          "code": "1412380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL ALL 48-100's",
      "code_information": [
        {
          "code": "1412394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 85.0833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX ALL SZ",
      "code_information": [
        {
          "code": "1413165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 591,
          "minimum": 202.0421,
          "maximum": 428.8887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 394.5776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX ALL SZ",
      "code_information": [
        {
          "code": "1413170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 523,
          "minimum": 120.6737,
          "maximum": 379.5411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 349.1778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN ALL SZS G01xxx",
      "code_information": [
        {
          "code": "1414845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 285.2793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.6989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY ALL SZS",
      "code_information": [
        {
          "code": "1414866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 757.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 284.4163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-10      G01112",
      "code_information": [
        {
          "code": "1414935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "1414990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 77.9452,
          "maximum": 165.4596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.2228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X     C20xxA",
      "code_information": [
        {
          "code": "1414995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-IV SILVERSITE 1X7MM",
      "code_information": [
        {
          "code": "1415449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 2767.7097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-VASCULAR 6MM X 7MM X 5FR",
      "code_information": [
        {
          "code": "1415480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT GASTRO INITIAL SM",
      "code_information": [
        {
          "code": "1415943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 987,
          "minimum": 337.4206,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 658.9646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-150 ML ILLUMENA 900103",
      "code_information": [
        {
          "code": "1416100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 2008.0771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGIOGRAPHY    MCBK001-07",
      "code_information": [
        {
          "code": "1416236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 783,
          "minimum": 267.6802,
          "maximum": 1974.7111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 522.7653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22FR   0250-22",
      "code_information": [
        {
          "code": "1416370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 396.4993,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1046.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENTUIT THRIVE 14F",
      "code_information": [
        {
          "code": "1416371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 713,
          "minimum": 243.7496,
          "maximum": 1623.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 476.0302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-INDIGO             IST3",
      "code_information": [
        {
          "code": "1416377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2920,
          "minimum": 998.2454,
          "maximum": 2119.044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1949.5205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1419101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX11C",
      "code_information": [
        {
          "code": "1419112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX15C",
      "code_information": [
        {
          "code": "1419113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 20GX15C",
      "code_information": [
        {
          "code": "1419114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX11C",
      "code_information": [
        {
          "code": "1419116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX15C",
      "code_information": [
        {
          "code": "1419118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 601,
          "minimum": 205.4608,
          "maximum": 436.1457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 401.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX20C",
      "code_information": [
        {
          "code": "1419119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 601,
          "minimum": 205.4608,
          "maximum": 436.1457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 401.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY  20GX11C",
      "code_information": [
        {
          "code": "1419293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 451,
          "minimum": 154.1811,
          "maximum": 556.6561,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 301.1074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-BIOPSY EVIVA 9G",
      "code_information": [
        {
          "code": "1495152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 39.4831,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-TISSUE ATEC        TF-1",
      "code_information": [
        {
          "code": "1495228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-EVIVA STX   0913-12T",
      "code_information": [
        {
          "code": "1495304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 172.9471,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE MULTICARE  MME-00347",
      "code_information": [
        {
          "code": "1495418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 352.5674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 207.6373,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC",
      "code_information": [
        {
          "code": "2395902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 79.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.4408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC 50MM",
      "code_information": [
        {
          "code": "2395904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 310.8599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.4408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAT-SURGISAFE ABSORBANT FLOOR",
      "code_information": [
        {
          "code": "3000001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 323,
          "minimum": 110.4223,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-FULL RADIUS 5.5MM",
      "code_information": [
        {
          "code": "3000006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 598.209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO               2C4040",
      "code_information": [
        {
          "code": "3000090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CONFIDENCE 2839-99-002",
      "code_information": [
        {
          "code": "3000520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-HEMOSTASES  HC0001",
      "code_information": [
        {
          "code": "3000742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1597,
          "minimum": 545.9582,
          "maximum": 1158.9429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1066.2275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-CLIP MED/LG 20 SMC",
      "code_information": [
        {
          "code": "3000753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 141.8055,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 672.3175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP PK AM0004",
      "code_information": [
        {
          "code": "3000760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 185.0535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP    AM0005",
      "code_information": [
        {
          "code": "3000762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 11638.0608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 213.6461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP  DISP   MCM20",
      "code_information": [
        {
          "code": "3000765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 518,
          "minimum": 177.086,
          "maximum": 375.9126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.8396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP LARGE MCL20",
      "code_information": [
        {
          "code": "3000766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 553,
          "minimum": 189.0513,
          "maximum": 401.3121,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 369.2071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP SM MCS20",
      "code_information": [
        {
          "code": "3000767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 569,
          "minimum": 194.5211,
          "maximum": 720.1495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 379.8894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-AUTOMATIC 5MM AE05ML",
      "code_information": [
        {
          "code": "3000770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 864.599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-ANASTOCLIP LARGE 15CM",
      "code_information": [
        {
          "code": "3000773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSISTANT-SUTURE 5MM     SW100",
      "code_information": [
        {
          "code": "3000865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1311,
          "minimum": 448.1848,
          "maximum": 2858.354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 875.2813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-UROLOGIC DRAIN     9501000",
      "code_information": [
        {
          "code": "3001113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 360.9089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 131.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-ANCHOR TISSUE ROBOTIC",
      "code_information": [
        {
          "code": "3001135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 649,
          "minimum": 221.8703,
          "maximum": 470.9793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 433.301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-ENDOPOUCH 10MM POUCH",
      "code_information": [
        {
          "code": "3001190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-DISPOSA 3MM       DBL-311",
      "code_information": [
        {
          "code": "3001371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 2990.1497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IPRISM IPC05",
      "code_information": [
        {
          "code": "3001669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAR-TIBIAL LOCKING      141205",
      "code_information": [
        {
          "code": "3002092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1493,
          "minimum": 313.6404,
          "maximum": 1083.4701,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 996.7925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 1.9X120 390-201",
      "code_information": [
        {
          "code": "3002152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1576,
          "minimum": 538.779,
          "maximum": 1143.7032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1052.2069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CEMENT-COMPACT VACUUM",
      "code_information": [
        {
          "code": "3002214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 99.5419,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.9431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           315.48",
      "code_information": [
        {
          "code": "3002244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1046.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.2      310.65",
      "code_information": [
        {
          "code": "3002246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 207.4253,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2217.9134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MINI DRILL AT2M-1813",
      "code_information": [
        {
          "code": "3002257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 1578.3975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1452.1257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145   03.010.104",
      "code_information": [
        {
          "code": "3002260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1668,
          "minimum": 570.2306,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1113.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    351.27",
      "code_information": [
        {
          "code": "3002270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3542,
          "minimum": 497.7095,
          "maximum": 2570.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2364.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM      03.010.036",
      "code_information": [
        {
          "code": "3002274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3373,
          "minimum": 1153.1102,
          "maximum": 2447.7861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2251.9632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.060",
      "code_information": [
        {
          "code": "3002289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2190,
          "minimum": 521.0657,
          "maximum": 1589.283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1462.1404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5           310.23",
      "code_information": [
        {
          "code": "3002291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 937,
          "minimum": 320.3274,
          "maximum": 679.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 625.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM         310.19",
      "code_information": [
        {
          "code": "3002294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 949,
          "minimum": 324.4298,
          "maximum": 688.6893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 633.5942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MMX150MM  511.417",
      "code_information": [
        {
          "code": "3002302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1642,
          "minimum": 561.3421,
          "maximum": 1191.5994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1096.2714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2 ALL 1806-4200s",
      "code_information": [
        {
          "code": "3002305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1134,
          "minimum": 387.6748,
          "maximum": 822.9438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 757.1083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X180MM 1806-4270S",
      "code_information": [
        {
          "code": "3002306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 156.8202,
          "maximum": 882.4512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 811.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR        5091-206",
      "code_information": [
        {
          "code": "3002318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 63.3954,
          "maximum": 204.6474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.2756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-STEP DRILL         357.403",
      "code_information": [
        {
          "code": "3002361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3578,
          "minimum": 712.9202,
          "maximum": 2596.5546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2388.8302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.4     310.530",
      "code_information": [
        {
          "code": "3002365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1282,
          "minimum": 438.2708,
          "maximum": 930.3474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 855.9196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           1806-5020S",
      "code_information": [
        {
          "code": "3002379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1219,
          "minimum": 416.7333,
          "maximum": 884.6283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 813.858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 03.113.024",
      "code_information": [
        {
          "code": "3002394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1440,
          "minimum": 492.2854,
          "maximum": 1045.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 961.4074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 03.113.023",
      "code_information": [
        {
          "code": "3002399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1440,
          "minimum": 492.2854,
          "maximum": 1045.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 961.4074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM 703542",
      "code_information": [
        {
          "code": "3002400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1284,
          "minimum": 438.9545,
          "maximum": 931.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 857.2549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3MM 703541",
      "code_information": [
        {
          "code": "3002402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1335,
          "minimum": 201.8643,
          "maximum": 968.8095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 891.3047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5085-2-032",
      "code_information": [
        {
          "code": "3002403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM 5085-2-040",
      "code_information": [
        {
          "code": "3002410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 1.7MM",
      "code_information": [
        {
          "code": "3002760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1755,
          "minimum": 599.9728,
          "maximum": 1273.6035,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1171.7152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO        1806-5000S",
      "code_information": [
        {
          "code": "3002772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1103,
          "minimum": 377.0769,
          "maximum": 1217.859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.4113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM     03.010.061",
      "code_information": [
        {
          "code": "3002776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2190,
          "minimum": 748.684,
          "maximum": 1589.283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1462.1404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM    03.010.101S",
      "code_information": [
        {
          "code": "3002777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 1578.3975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1452.1257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.6x",
      "code_information": [
        {
          "code": "3002779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2769,
          "minimum": 946.6238,
          "maximum": 2009.4633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1848.7062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL W/STOP ALL   324.15x",
      "code_information": [
        {
          "code": "3002780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2797,
          "minimum": 870.8526,
          "maximum": 2029.7829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1867.4003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.68",
      "code_information": [
        {
          "code": "3002782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2977,
          "minimum": 497.7095,
          "maximum": 2160.4089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1987.5762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 17MM    357.394",
      "code_information": [
        {
          "code": "3002785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4976,
          "minimum": 497.7095,
          "maximum": 3611.0832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3322.1965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM         700347",
      "code_information": [
        {
          "code": "3002791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1337,
          "minimum": 457.0733,
          "maximum": 970.2609,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 892.64,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1MM         702742",
      "code_information": [
        {
          "code": "3002793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1019,
          "minimum": 348.3603,
          "maximum": 739.4883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 680.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X110MM     310.35",
      "code_information": [
        {
          "code": "3002794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 921,
          "minimum": 314.8575,
          "maximum": 668.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 614.9001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER MINI       376900",
      "code_information": [
        {
          "code": "3002835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 618.9393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 9-9.5MM 5400-031-xxx",
      "code_information": [
        {
          "code": "3002951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1113,
          "minimum": 380.4956,
          "maximum": 807.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 743.0878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EXT ELECTRODE    E1551-6",
      "code_information": [
        {
          "code": "3002959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-TURBINATE INF SB2000SA",
      "code_information": [
        {
          "code": "3002962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1139,
          "minimum": 389.3841,
          "maximum": 826.5723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 760.4465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SERRATED STND SB4000SS",
      "code_information": [
        {
          "code": "3002963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 60.0588,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 867.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MYRINGOTOMY SPEAR TIP",
      "code_information": [
        {
          "code": "3003112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RAD 40 DEGREE 18-84006HR",
      "code_information": [
        {
          "code": "3003122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1727,
          "minimum": 590.4006,
          "maximum": 1253.2839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RADNOID 18-84008",
      "code_information": [
        {
          "code": "3003123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1721,
          "minimum": 588.3494,
          "maximum": 1248.9297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1149.0153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RASP SAW       510037113",
      "code_information": [
        {
          "code": "3003127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 289.7281,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 739.7496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW MICR 9MM 2296-3-100s",
      "code_information": [
        {
          "code": "3003143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 178.1116,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 347.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG SAW 9X25 ALL 2296s",
      "code_information": [
        {
          "code": "3003147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 62.2832,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 347.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 5.5MMX18MM  KM 3-412",
      "code_information": [
        {
          "code": "3003150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 177.952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW GIGLI ROUND  2808-01",
      "code_information": [
        {
          "code": "3003172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 33.366,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 213.6461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HEX COATED 2.75   E1450X",
      "code_information": [
        {
          "code": "3003200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 2242.1952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-INF TURB 2.0  18-82040HR",
      "code_information": [
        {
          "code": "3003227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2469,
          "minimum": 844.0643,
          "maximum": 1791.7533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1648.413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90Xxx    05.003.1xxS",
      "code_information": [
        {
          "code": "3003256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 967.0579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 416.6099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380HR",
      "code_information": [
        {
          "code": "3003258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1739,
          "minimum": 594.503,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1161.0329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS     519.xxxS",
      "code_information": [
        {
          "code": "3003292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 563.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 518.0917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CELL SAVER HI SP   CSP26x",
      "code_information": [
        {
          "code": "3003419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 777,
          "minimum": 265.629,
          "maximum": 563.8689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 518.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-SMARTMIX CTS    540176501",
      "code_information": [
        {
          "code": "3003433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-INTERNAL AR-1678-CP",
      "code_information": [
        {
          "code": "3003471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5500,
          "minimum": 554.9878,
          "maximum": 3991.35,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3672.042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-UNIV X-ACT 11-2151-9",
      "code_information": [
        {
          "code": "3003472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 998,
          "minimum": 89.5321,
          "maximum": 724.2486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 666.3087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-WHISTLE CLEANING  000101",
      "code_information": [
        {
          "code": "3003605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.7937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT RND 2296-100-421",
      "code_information": [
        {
          "code": "3003756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 154.5958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL CUTTING 5300-010-901",
      "code_information": [
        {
          "code": "3003762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 278,
          "minimum": 95.0384,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND          277-10-423",
      "code_information": [
        {
          "code": "3003782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.6989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND CUT 2.4MM  5091-225",
      "code_information": [
        {
          "code": "3003786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 66.732,
          "maximum": 175.6194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 161.5698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT 1.6   277-10-xxx",
      "code_information": [
        {
          "code": "3003792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 347.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.1173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-WATERMELON      1607-2-35",
      "code_information": [
        {
          "code": "3003805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 708.4714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 416.6099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL   SP-7810",
      "code_information": [
        {
          "code": "3003812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1274,
          "minimum": 435.5358,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 850.5785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 2MM 5820-013-0xx",
      "code_information": [
        {
          "code": "3003829",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 300.294,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 852.5814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND 4.0MM    277-10-240",
      "code_information": [
        {
          "code": "3003855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.3079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 5MM     5820-013-050",
      "code_information": [
        {
          "code": "3003856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING BLUE   FL-601-97B",
      "code_information": [
        {
          "code": "3003905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.3049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT STERILE MAS PLIF",
      "code_information": [
        {
          "code": "3003914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 5832.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1904.7883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ARCH 6.5  80320",
      "code_information": [
        {
          "code": "3004042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.0195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO DBL 5MM PAL-505LL",
      "code_information": [
        {
          "code": "3004047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 86.1955,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY PREMATURE",
      "code_information": [
        {
          "code": "3004048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY NEONATAL",
      "code_information": [
        {
          "code": "3004049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERPAY INFANT",
      "code_information": [
        {
          "code": "3004051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 411.514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-308LS",
      "code_information": [
        {
          "code": "3004052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 537.018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 494.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CURVED 100MM 20G 10.0M",
      "code_information": [
        {
          "code": "3004190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.6989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX FEM TFA-022-25",
      "code_information": [
        {
          "code": "3004225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 441.9513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 406.5952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX       TFA02025",
      "code_information": [
        {
          "code": "3004226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 406.5952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 27FR 96370-027",
      "code_information": [
        {
          "code": "3004235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1777,
          "minimum": 607.4939,
          "maximum": 1289.5689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1186.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-5FR RAD PIGTAIL 5RPS110-N",
      "code_information": [
        {
          "code": "3004842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 364,
          "minimum": 124.4388,
          "maximum": 1145.0099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 243.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TACKER DELIVERY OMS-TTS",
      "code_information": [
        {
          "code": "3005077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3218,
          "minimum": 870.8526,
          "maximum": 2335.3026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2148.4784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHLOANGIOGRAM   20018-010",
      "code_information": [
        {
          "code": "3005234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 613,
          "minimum": 110.6639,
          "maximum": 444.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 409.2658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 24Fr 5CC 265724",
      "code_information": [
        {
          "code": "3005414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 574.4513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3WAY         73022L",
      "code_information": [
        {
          "code": "3005435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 1478.6699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.1701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-PASSER            8591-38",
      "code_information": [
        {
          "code": "3006601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1761.7248,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 34FR-46FR ALL",
      "code_information": [
        {
          "code": "3007230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 442.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 407.2628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 36FR-46FR  TF36460",
      "code_information": [
        {
          "code": "3007235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 442.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 407.2628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP         AA01",
      "code_information": [
        {
          "code": "3007600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.4408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-ACU-DISPO      DCFT2",
      "code_information": [
        {
          "code": "3007601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 1595.4509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP,MULTI-PIN LG 390.004",
      "code_information": [
        {
          "code": "3008494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4727,
          "minimum": 1615.9952,
          "maximum": 3430.3839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3155.9532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-NV DSC & IN-LINE ACTIVATO",
      "code_information": [
        {
          "code": "3008690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 432.0897,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LAPRA-TY ABS SUTURE XC200",
      "code_information": [
        {
          "code": "3008699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 777,
          "minimum": 52.2734,
          "maximum": 563.8689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 518.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIPS-HEM-O-LOC         544230",
      "code_information": [
        {
          "code": "3008728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.7585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK LG       544240",
      "code_information": [
        {
          "code": "3008730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.0762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK XL       544250",
      "code_information": [
        {
          "code": "3008731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X3/8 XA6062",
      "code_information": [
        {
          "code": "3009659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 871,
          "minimum": 297.7643,
          "maximum": 2382.3324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 581.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR ACCU-FLO 82-1504",
      "code_information": [
        {
          "code": "3009774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 387.3329,
          "maximum": 2246.0879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 756.4407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONSTAVAC-CBC II    225-28-614",
      "code_information": [
        {
          "code": "3009792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1463,
          "minimum": 83.415,
          "maximum": 1061.6991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.7632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR BOVIE DISP 301538",
      "code_information": [
        {
          "code": "3009842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 155.708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR HIGH   26176LD/10",
      "code_information": [
        {
          "code": "3009843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 1074.9413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.9403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNULATED",
      "code_information": [
        {
          "code": "3009845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1933,
          "minimum": 660.8248,
          "maximum": 1402.7781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1290.5559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNUL 3.8MM",
      "code_information": [
        {
          "code": "3009850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 50.049,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1201.0916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-SILICONE RETRACTOR",
      "code_information": [
        {
          "code": "3009851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 158.4885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-DISPOSABLE ACTIVE DAC",
      "code_information": [
        {
          "code": "3009853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 1787.3054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 190.2785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-8 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 187.2306,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.2522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 206.8245,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 190.2785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 10191.6447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.9726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 252.5436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 232.3401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-30 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 248.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 428,
          "minimum": 146.3182,
          "maximum": 310.5996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 285.7516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MERCEDES     PAL-506LL",
      "code_information": [
        {
          "code": "3010053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 2360.0884,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS ALL SZS   681xx",
      "code_information": [
        {
          "code": "3010076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 551,
          "minimum": 188.3675,
          "maximum": 2007.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 367.8718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT ALL SZ",
      "code_information": [
        {
          "code": "3010079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 1508.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.04,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL 1X4  2111-04-077",
      "code_information": [
        {
          "code": "3010088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2712,
          "minimum": 927.1375,
          "maximum": 3166.9895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1810.6505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL ALL  2111-08-07x",
      "code_information": [
        {
          "code": "3010090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5695,
          "minimum": 265.2597,
          "maximum": 4132.8615,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3802.2326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X20 657320",
      "code_information": [
        {
          "code": "3010104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 909.3311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X40 657340",
      "code_information": [
        {
          "code": "3010107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 909.3311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DUBIN              8390",
      "code_information": [
        {
          "code": "3010215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 494.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION         BID30",
      "code_information": [
        {
          "code": "3010259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 890,
          "minimum": 265.8158,
          "maximum": 645.873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 594.2032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE TISSUE REMOVAL",
      "code_information": [
        {
          "code": "3010310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1901.3059,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LAPARSCOP PLUME FILTER",
      "code_information": [
        {
          "code": "3010330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 198,
          "minimum": 67.6892,
          "maximum": 5379.1553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.1935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VAGINAL POSITIONING",
      "code_information": [
        {
          "code": "3010598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2367,
          "minimum": 809.1941,
          "maximum": 1717.7319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1580.3133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-BLUNT TIP 5 PK BTD05",
      "code_information": [
        {
          "code": "3010867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1 5901-1126",
      "code_information": [
        {
          "code": "3011002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 207.4253,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 558.1504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHAN W/TROCAR ALL SIZES",
      "code_information": [
        {
          "code": "3011730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 199,
          "minimum": 43.3758,
          "maximum": 144.4143,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.8612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT HUBLESS ALL SZS",
      "code_information": [
        {
          "code": "3011780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.0762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-MINI CHEST 500     16400",
      "code_information": [
        {
          "code": "3011787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1139,
          "minimum": 389.3841,
          "maximum": 826.5723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 760.4465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FECAL MANAGEMENT 418000",
      "code_information": [
        {
          "code": "3011910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1469,
          "minimum": 36.1465,
          "maximum": 1066.0533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 980.769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FECAL MANAGEMENT 411108",
      "code_information": [
        {
          "code": "3011911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 120.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-HIP W/POUCHES DYNJP8201",
      "code_information": [
        {
          "code": "3011920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 217,
          "minimum": 74.1847,
          "maximum": 157.4769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.8787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BEACH CHAIR SHOULDER",
      "code_information": [
        {
          "code": "3011922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 257,
          "minimum": 87.8593,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.5845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BARIATRIC      DYNJP3105",
      "code_information": [
        {
          "code": "3011926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 77.9452,
          "maximum": 271.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.2228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-DOUBLE 44X66     ORS 320",
      "code_information": [
        {
          "code": "3011927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 325.8103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 12MM CD004",
      "code_information": [
        {
          "code": "3011949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 32.2538,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE 3M SHORT   6661EZ",
      "code_information": [
        {
          "code": "3011953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 148.4787,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-ISO IOBAN HIP       6617",
      "code_information": [
        {
          "code": "3011959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 200.196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.2609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INTESTINAL 18X18.5 ISO1003",
      "code_information": [
        {
          "code": "3011960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 360,
          "minimum": 123.0713,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 240.3518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 10MM CD001",
      "code_information": [
        {
          "code": "3011961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 44.488,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI     326088-0000-000",
      "code_information": [
        {
          "code": "3011985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 155.1519,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.4115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI FULL         306070",
      "code_information": [
        {
          "code": "3011987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 279,
          "minimum": 95.3803,
          "maximum": 328.6551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.2727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER           ORS-400",
      "code_information": [
        {
          "code": "3011995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 591,
          "minimum": 33.366,
          "maximum": 428.8887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 394.5776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERI IRRIGATION    1016",
      "code_information": [
        {
          "code": "3012018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 68.9564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE HAND   DYNJP8005",
      "code_information": [
        {
          "code": "3012025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 89.9868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.7879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR GLASSCOCK  S-1000",
      "code_information": [
        {
          "code": "3012051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 266.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 207.6373,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GENTLE CARE SURG 12-1",
      "code_information": [
        {
          "code": "3012060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 480,
          "minimum": 164.0951,
          "maximum": 348.336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 320.4691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-TOPIFOAM      5710-30",
      "code_information": [
        {
          "code": "3012080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 57.2783,
          "maximum": 216.9843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 199.6256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED ASNIS III",
      "code_information": [
        {
          "code": "3012111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1063.8193,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.5MM  702450",
      "code_information": [
        {
          "code": "3012114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 673.4371,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-HEX 1.1X67       15-1723",
      "code_information": [
        {
          "code": "3012115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1211,
          "minimum": 413.9983,
          "maximum": 878.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 808.5169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3012118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1046.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST ASNIS III 6.5MM",
      "code_information": [
        {
          "code": "3012151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN 4.0MM W/AO",
      "code_information": [
        {
          "code": "3012152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5392,
          "minimum": 813.0182,
          "maximum": 3912.9744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3599.9364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SHAFT-AO 2.6MMX122MM",
      "code_information": [
        {
          "code": "3012186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           310.48",
      "code_information": [
        {
          "code": "3012201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1176,
          "minimum": 402.0331,
          "maximum": 853.4232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 785.1493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1806-5010S",
      "code_information": [
        {
          "code": "3012206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1103,
          "minimum": 377.0769,
          "maximum": 800.4471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 736.4113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 03.6MMX122MM",
      "code_information": [
        {
          "code": "3012207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1378,
          "minimum": 471.0898,
          "maximum": 1000.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 920.0134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 13.0MM CANNULATED",
      "code_information": [
        {
          "code": "3012314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4464,
          "minimum": 540.5292,
          "maximum": 3239.5248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2980.3628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         MS-DCR20",
      "code_information": [
        {
          "code": "3012321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 959.2725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.4055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 LG 120MM",
      "code_information": [
        {
          "code": "3012325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1725,
          "minimum": 589.7169,
          "maximum": 1251.8325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1151.6859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 315.28",
      "code_information": [
        {
          "code": "3012330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1374,
          "minimum": 469.7223,
          "maximum": 997.1118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 917.3429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X40   2274-12-000",
      "code_information": [
        {
          "code": "3012344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1940,
          "minimum": 586.6855,
          "maximum": 1407.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1295.2294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5          MS-DC35",
      "code_information": [
        {
          "code": "3012346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1055,
          "minimum": 360.6674,
          "maximum": 765.6135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 704.3644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.201",
      "code_information": [
        {
          "code": "3012355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 912,
          "minimum": 311.7808,
          "maximum": 661.8384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 608.8913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL               310.28",
      "code_information": [
        {
          "code": "3012356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 784.6571,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 648.95,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.431",
      "code_information": [
        {
          "code": "3012357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1411,
          "minimum": 482.3713,
          "maximum": 1023.9627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 942.0457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL            32-486265",
      "code_information": [
        {
          "code": "3012365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 769,
          "minimum": 262.8941,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 513.4182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL         5820-107-530",
      "code_information": [
        {
          "code": "3012374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 1340.201,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           AT2M-L1813",
      "code_information": [
        {
          "code": "3012378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2410,
          "minimum": 823.8943,
          "maximum": 1748.937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1609.022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED   310.634",
      "code_information": [
        {
          "code": "3012380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1784.6124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 5.0MM",
      "code_information": [
        {
          "code": "3012381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1784.6124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM 60-19340",
      "code_information": [
        {
          "code": "3012401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1102,
          "minimum": 376.7351,
          "maximum": 799.7214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 735.7437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHRT 3.2 03.010.103S",
      "code_information": [
        {
          "code": "3012406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1666,
          "minimum": 569.5469,
          "maximum": 1209.0162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1112.2949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL 5MM     DBL-511",
      "code_information": [
        {
          "code": "3012461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL LOOP      B0512",
      "code_information": [
        {
          "code": "3012465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 51.1612,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 248.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X2.75 E1455",
      "code_information": [
        {
          "code": "3012472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X4  E1455-4",
      "code_information": [
        {
          "code": "3012473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 762.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-208",
      "code_information": [
        {
          "code": "3012474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1372,
          "minimum": 469.0386,
          "maximum": 995.6604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 916.0076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EZ CLEAN CAUTERY TIP",
      "code_information": [
        {
          "code": "3012505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 43.3758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.0528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE MOD     0014AM",
      "code_information": [
        {
          "code": "3012507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.0762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BOVIE RED      E7507",
      "code_information": [
        {
          "code": "3012513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 231.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK  E2773-45",
      "code_information": [
        {
          "code": "3012520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 61.7271,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 278.4075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MRI CONDITIONAL DISP",
      "code_information": [
        {
          "code": "3012521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 1396.9232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LIGASURE      LS1037",
      "code_information": [
        {
          "code": "3012535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2512,
          "minimum": 858.7645,
          "maximum": 1822.9584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1677.1217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 2CHAN 8227410",
      "code_information": [
        {
          "code": "3012585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1545,
          "minimum": 528.1812,
          "maximum": 1121.2065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1031.51,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-RADIUS LOOP    R1010",
      "code_information": [
        {
          "code": "3012596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 41.7075,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 248.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 6.5\\\" 0014M",
      "code_information": [
        {
          "code": "3012611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 54.4275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.0733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-TEFLON 6 1/2 BLADE",
      "code_information": [
        {
          "code": "3012613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDCAP-ROUND X-CORE    5960200",
      "code_information": [
        {
          "code": "3012635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4702,
          "minimum": 1037.1265,
          "maximum": 3412.2414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3139.2621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3012680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2877,
          "minimum": 983.5452,
          "maximum": 2974.5789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1920.8118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVACUATOR-UROVAC       730-125",
      "code_information": [
        {
          "code": "3012699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 100.098,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.6725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVAC-SAF-T-VAC         ST9000S",
      "code_information": [
        {
          "code": "3012723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 667.8761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.1759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-GLUE             540133500",
      "code_information": [
        {
          "code": "3012805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 199.0838,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXCISOR-BIOPSY CONE",
      "code_information": [
        {
          "code": "3012815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-DIALYSIS CATH  415612",
      "code_information": [
        {
          "code": "3012854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1265,
          "minimum": 432.459,
          "maximum": 918.0105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 844.5697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTRACTOR-TRIGEN DISP 71631320",
      "code_information": [
        {
          "code": "3012895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.9431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBE-VIPERSLIDE VPR-SLD2",
      "code_information": [
        {
          "code": "3012925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 558.1504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 1X6        007976",
      "code_information": [
        {
          "code": "3012991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 1153.3514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 648.2823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 4\\\"X4\\\"       007836",
      "code_information": [
        {
          "code": "3012993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2074,
          "minimum": 709.0277,
          "maximum": 7269.3392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1384.6937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 200M",
      "code_information": [
        {
          "code": "3013060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2420,
          "minimum": 827.313,
          "maximum": 1756.194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1615.6985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 365M",
      "code_information": [
        {
          "code": "3013061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2010,
          "minimum": 687.1484,
          "maximum": 1473.1089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1341.9644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 550M",
      "code_information": [
        {
          "code": "3013062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2649,
          "minimum": 905.6,
          "maximum": 2081.4823,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1768.589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 1000M",
      "code_information": [
        {
          "code": "3013063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3743,
          "minimum": 1066.0437,
          "maximum": 2716.2951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2498.9915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-COUDE HEYMAN   021300",
      "code_information": [
        {
          "code": "3013087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1917,
          "minimum": 655.3549,
          "maximum": 1391.1669,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1279.8735,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-HEYMAN         021100",
      "code_information": [
        {
          "code": "3013090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1718,
          "minimum": 365.3577,
          "maximum": 1246.7526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1147.0124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPER-          AR-7237-7",
      "code_information": [
        {
          "code": "3013107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 1783.4127,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 3  AR-7227-01",
      "code_information": [
        {
          "code": "3013134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 238.7553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 219.6549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 4  AR-7230-01",
      "code_information": [
        {
          "code": "3013135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 43.3758,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.0195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-HEPA BACTERIA 00182",
      "code_information": [
        {
          "code": "3013160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.0762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PED OXYKID W/7' TUBING",
      "code_information": [
        {
          "code": "3013161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 75.6296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-INSUFFLATION BULB",
      "code_information": [
        {
          "code": "3013164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 131.7957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP     1599-05",
      "code_information": [
        {
          "code": "3013203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 237,
          "minimum": 81.022,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 158.2316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-PIRANHA 3FR     505-160",
      "code_information": [
        {
          "code": "3013317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2055,
          "minimum": 69.5125,
          "maximum": 1491.3135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1372.0084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW      000300s",
      "code_information": [
        {
          "code": "3013320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 90.7125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.4555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GEL-PROLARYN          8602M0K5",
      "code_information": [
        {
          "code": "3013462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4034,
          "minimum": 1379.0828,
          "maximum": 52874.5441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2693.2759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3014234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.6469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 6.5 DRILL",
      "code_information": [
        {
          "code": "3014235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-AR-8737-01",
      "code_information": [
        {
          "code": "3014239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3014272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 3372.7465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.8172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-DBX MIX 2.5CC     058025",
      "code_information": [
        {
          "code": "3014900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2432,
          "minimum": 831.4153,
          "maximum": 2273.3368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1623.7102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-HELI-FX            SG-64",
      "code_information": [
        {
          "code": "3016110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 107.8834,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-WIRE .035      WS-0906ST",
      "code_information": [
        {
          "code": "3016121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.5229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2MM           292.65",
      "code_information": [
        {
          "code": "3016129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 552,
          "minimum": 188.7094,
          "maximum": 400.5864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 368.5395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K SMOOTH TIP AGK16100",
      "code_information": [
        {
          "code": "3016134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 606.7051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.3049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-3.2       03.010.115",
      "code_information": [
        {
          "code": "3016135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1091,
          "minimum": 372.9746,
          "maximum": 791.7387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 728.3996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K W/OLIVE STOP",
      "code_information": [
        {
          "code": "3016136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 263.5914,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 941.378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-SUT GABBY-FRATER SUT 013",
      "code_information": [
        {
          "code": "3016153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 695.125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.9403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP AR894301",
      "code_information": [
        {
          "code": "3016164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 199.6256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-HALTER DISP 08143101",
      "code_information": [
        {
          "code": "3016272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 118,
          "minimum": 40.3401,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ADHESIVE 4\\\" WHITE",
      "code_information": [
        {
          "code": "3016326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 58022.9179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1963",
      "code_information": [
        {
          "code": "3016347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1292,
          "minimum": 114.5566,
          "maximum": 937.6044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 862.596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOVAC-400ML LG   2550-004-10",
      "code_information": [
        {
          "code": "3016381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 1215.6346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.5347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-HYDRODEB     1914001",
      "code_information": [
        {
          "code": "3016387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2186,
          "minimum": 747.3166,
          "maximum": 1586.3802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1459.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM SNGL PK 33508G",
      "code_information": [
        {
          "code": "3016420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 2308.9272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.5229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM DOUBLE  3384-4",
      "code_information": [
        {
          "code": "3016425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 434,
          "minimum": 148.3693,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 289.7575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 2X4 2082",
      "code_information": [
        {
          "code": "3016450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 704.6547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 648.2823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 4X4 2083",
      "code_information": [
        {
          "code": "3016451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1255,
          "minimum": 429.0404,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 837.8932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-J CAUTERY     60-5272-232",
      "code_information": [
        {
          "code": "3016500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.9345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-ULTRASLING III XLG",
      "code_information": [
        {
          "code": "3017486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 347.5625,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 288.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUTTLE-ACCU PASS SUTURE 70DEG",
      "code_information": [
        {
          "code": "3019705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1334,
          "minimum": 456.0477,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 890.6371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-EVERGRIP LF  EVERGRIP61",
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        {
          "code": "3019748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 322,
          "minimum": 110.0805,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.9814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FDG",
      "code_information": [
        {
          "code": "3019810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2674,
          "minimum": 914.1466,
          "maximum": 1940.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.2801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGL",
      "code_information": [
        {
          "code": "3019813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 914.1466,
          "maximum": 1940.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1785.2801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGD",
      "code_information": [
        {
          "code": "3019815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3010,
          "minimum": 1029.0132,
          "maximum": 2184.357,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2009.6084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-PEELAWAY 16F",
      "code_information": [
        {
          "code": "3019878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 615,
          "minimum": 210.2469,
          "maximum": 446.3055,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.6011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT 9FR 3 1/2 PI93",
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        {
          "code": "3019879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 381,
          "minimum": 130.2505,
          "maximum": 276.4917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 254.3724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2MM 500373",
      "code_information": [
        {
          "code": "3020202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 709,
          "minimum": 242.3822,
          "maximum": 589.466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 473.3596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPER DISTRACTOR FF904SB",
      "code_information": [
        {
          "code": "3020203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1060,
          "minimum": 362.3768,
          "maximum": 769.242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 707.7026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 17L 96550",
      "code_information": [
        {
          "code": "3020800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 515,
          "minimum": 176.0604,
          "maximum": 2737.6803,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 343.8367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-I RING PUPIL 587000",
      "code_information": [
        {
          "code": "3020804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1251,
          "minimum": 427.6729,
          "maximum": 907.8507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 835.2226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL VISULIZATION",
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        {
          "code": "3020806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUG 03.804.522S",
      "code_information": [
        {
          "code": "3020807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 859,
          "minimum": 56.7222,
          "maximum": 623.3763,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 573.5062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SCOPE WARMER TM500",
      "code_information": [
        {
          "code": "3020808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 250.8011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.0997,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENTI SCAN IV DISP 177-092",
      "code_information": [
        {
          "code": "3020810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 451,
          "minimum": 154.1811,
          "maximum": 3042.9792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 301.1074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESSORY 700     72401850",
      "code_information": [
        {
          "code": "3020811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5472,
          "minimum": 1870.6845,
          "maximum": 3971.0304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3653.348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COAG  CSP208",
      "code_information": [
        {
          "code": "3020850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 2343.4054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DILATOR NVM5       2029950",
      "code_information": [
        {
          "code": "3020915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 757.4082,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3201.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-19",
      "code_information": [
        {
          "code": "3020920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 1248.4445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 909.3311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-21",
      "code_information": [
        {
          "code": "3020922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2245,
          "minimum": 497.7095,
          "maximum": 1629.1965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1498.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC     96530-017",
      "code_information": [
        {
          "code": "3020928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1177,
          "minimum": 402.3749,
          "maximum": 2227.1805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 785.817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IV MAXCESS         3240060",
      "code_information": [
        {
          "code": "3020969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8227,
          "minimum": 2812.5222,
          "maximum": 8921.5123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5492.7072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX PT STARTER  50-0071",
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        {
          "code": "3021029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2289,
          "minimum": 782.5287,
          "maximum": 2001.4039,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1528.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHUNT NONINVASIVE  9733605",
      "code_information": [
        {
          "code": "3021032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3599,
          "minimum": 895.321,
          "maximum": 2611.7943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2402.8508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 4ML 1501262",
      "code_information": [
        {
          "code": "3021034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1610,
          "minimum": 264.7036,
          "maximum": 1168.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1074.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH&BOOT 3550-80",
      "code_information": [
        {
          "code": "3021046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 476,
          "minimum": 162.7277,
          "maximum": 1362.445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 317.7985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERITONEAL DIALYSIS 278006",
      "code_information": [
        {
          "code": "3021065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1150,
          "minimum": 96.2053,
          "maximum": 834.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHOULDER CANNULA 5CM  9718",
      "code_information": [
        {
          "code": "3021080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 974.8433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.5024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-URO MAX HI PRESURE 225-136",
      "code_information": [
        {
          "code": "3021090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1753,
          "minimum": 599.2891,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1170.3799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXTRACTION GTG14",
      "code_information": [
        {
          "code": "3021113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4570,
          "minimum": 1562.3224,
          "maximum": 3316.449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3051.1331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X12MM 663812",
      "code_information": [
        {
          "code": "3021130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 951,
          "minimum": 67.2881,
          "maximum": 690.1407,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 634.9294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE,SLIT 2.4MM 45 DEGREE",
      "code_information": [
        {
          "code": "3021161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 1114.4244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 175.5904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-GRAFT ACL 10MM    232110",
      "code_information": [
        {
          "code": "3021173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2004,
          "minimum": 271.3768,
          "maximum": 1454.3028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1337.9586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT CLEAR CUT 2.4",
      "code_information": [
        {
          "code": "3021199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 58.9466,
          "maximum": 354.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 325.8103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDE PORT 1.1    78-2010",
      "code_information": [
        {
          "code": "3021203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 937.5846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-TUIP             880-217",
      "code_information": [
        {
          "code": "3021220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 749,
          "minimum": 256.0568,
          "maximum": 667.8761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 500.0654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE ALL AR-4000Ss",
      "code_information": [
        {
          "code": "3021225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE         AR-4068's",
      "code_information": [
        {
          "code": "3021227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 4811.9333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDEPORT SAFETY 1.0MM",
      "code_information": [
        {
          "code": "3021241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 110.7642,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.3167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINER-SZ25/36MM RL 12-105995",
      "code_information": [
        {
          "code": "3021635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4400,
          "minimum": 1504.2054,
          "maximum": 8241.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-IMPACT         LF4318",
      "code_information": [
        {
          "code": "3021733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2708,
          "minimum": 145.1421,
          "maximum": 1965.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1807.98,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-DRAINAGE LOCKABLE 50-7245",
      "code_information": [
        {
          "code": "3021737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 174.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 26FR      880-214",
      "code_information": [
        {
          "code": "3021821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 134.0201,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 463.3449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-DISPOSA ALL",
      "code_information": [
        {
          "code": "3021826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-ELECTRODE 24FR   WA22037C",
      "code_information": [
        {
          "code": "3021880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1483,
          "minimum": 326.4307,
          "maximum": 1076.2131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 990.1161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WIRE SNARE 8-14515",
      "code_information": [
        {
          "code": "3021881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 1048.8046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 391.907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-MS SSEP NEEDLE  8050315",
      "code_information": [
        {
          "code": "3022945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5246,
          "minimum": 1793.4231,
          "maximum": 3807.0222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3502.4604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE EMG 8050015",
      "code_information": [
        {
          "code": "3022950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE MEP/EMG",
      "code_information": [
        {
          "code": "3022955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 4022.8274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3389.6286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SINGLE PORT PAL 240LS",
      "code_information": [
        {
          "code": "3023177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 4022.8274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 531.4446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY STEALTH  9733068",
      "code_information": [
        {
          "code": "3027284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4784,
          "minimum": 117.8932,
          "maximum": 3471.7488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3194.0089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY TRU CUT 2N2700s",
      "code_information": [
        {
          "code": "3027285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 153.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 141.5405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY CUT      4418-16",
      "code_information": [
        {
          "code": "3027295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 413.7384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DEFLUX 23GX3.7FX350mm",
      "code_information": [
        {
          "code": "3027296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 744,
          "minimum": 254.3475,
          "maximum": 539.9208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 496.7271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DISP INSUF      S100000",
      "code_information": [
        {
          "code": "3027310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 482,
          "minimum": 45.0441,
          "maximum": 349.7874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.8044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ELECTRODE COATD E1465-6",
      "code_information": [
        {
          "code": "3027313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 399.8359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ENDOPATH INSUFF   PN120",
      "code_information": [
        {
          "code": "3027315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 719,
          "minimum": 245.8008,
          "maximum": 521.7783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 480.036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL       105-1314",
      "code_information": [
        {
          "code": "3027318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 88.4199,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-20      G00013",
      "code_information": [
        {
          "code": "3027330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 230.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FORAMEN 20G      041829",
      "code_information": [
        {
          "code": "3027344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 301.1655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 277.0723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-6 DJ6011X",
      "code_information": [
        {
          "code": "3027346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 292,
          "minimum": 99.8245,
          "maximum": 216.879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 194.952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR        1650050",
      "code_information": [
        {
          "code": "3027347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 390,
          "minimum": 125.6786,
          "maximum": 283.023,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 260.3812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSULATED EDGE   E1465B",
      "code_information": [
        {
          "code": "3027368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 77.2615,
          "maximum": 719.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TR-CRON 2-0 STR W/10 SW",
      "code_information": [
        {
          "code": "3027402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 437,
          "minimum": 149.3949,
          "maximum": 348.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 291.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR W/SHEATH",
      "code_information": [
        {
          "code": "3027403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 626,
          "minimum": 214.0074,
          "maximum": 454.2882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 417.9451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OPUS SPEEDSTITCH",
      "code_information": [
        {
          "code": "3027425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 397,
          "minimum": 135.7203,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 265.0547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OCTRODE 6\\\"         1116",
      "code_information": [
        {
          "code": "3027430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODESSECTION   N103A",
      "code_information": [
        {
          "code": "3027433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 690,
          "minimum": 235.8868,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 460.6744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION      AR-13991N",
      "code_information": [
        {
          "code": "3027443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 440.9873,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SIDEKICK 21GA 14.6\\\"",
      "code_information": [
        {
          "code": "3027445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 793,
          "minimum": 207.4253,
          "maximum": 575.4801,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 529.4417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODISSECTION   E1xxx",
      "code_information": [
        {
          "code": "3027520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 795,
          "minimum": 45.0441,
          "maximum": 576.9315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 530.777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-W/BASEPLATE BSDN-18-7.0",
      "code_information": [
        {
          "code": "3027587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 722.3739,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 5MM  VS101005",
      "code_information": [
        {
          "code": "3027591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1299,
          "minimum": 444.0825,
          "maximum": 942.6843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 867.2696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VERSASTEP 14GA VS150000",
      "code_information": [
        {
          "code": "3027593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 600,
          "minimum": 205.1189,
          "maximum": 680.6664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 400.5864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TROCAR 12MM VS101000s",
      "code_information": [
        {
          "code": "3027595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1224,
          "minimum": 418.4426,
          "maximum": 888.2568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 817.1963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-WILSON PENILE IMPLANT",
      "code_information": [
        {
          "code": "3029175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2504,
          "minimum": 856.0296,
          "maximum": 1817.1528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1671.7806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FENWAL TRANSFER 4R2014",
      "code_information": [
        {
          "code": "3029199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 373.1431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.0997,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-EXTREMITY      DYNJ31779F",
      "code_information": [
        {
          "code": "3029200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 671,
          "minimum": 75.6296,
          "maximum": 486.9447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 447.9891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAGNETIC DRAPE    31140562",
      "code_information": [
        {
          "code": "3029201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 1966.3696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY ELITE VIAL     LC3001",
      "code_information": [
        {
          "code": "3029202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3536,
          "minimum": 1208.8341,
          "maximum": 2566.0752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2360.7892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SENSA TRAC M8275057/10",
      "code_information": [
        {
          "code": "3029214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 196.6647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-PERFUSION CUSTOM  CK0226R",
      "code_information": [
        {
          "code": "3029252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3994,
          "minimum": 145.1421,
          "maximum": 2898.4458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2666.5701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SHOULDER ARTHROSCOP 29367",
      "code_information": [
        {
          "code": "3029266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 189.4077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 174.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SINUS KENNEDY      400422",
      "code_information": [
        {
          "code": "3029267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 656.198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-TOTAL JOINT    DYNJ31778A",
      "code_information": [
        {
          "code": "3029268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1180,
          "minimum": 99.5419,
          "maximum": 856.326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 787.8199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM     440400",
      "code_information": [
        {
          "code": "3029278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAK-CONFIDENCE PLUS",
      "code_information": [
        {
          "code": "3029292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HAND DYNJ52365",
      "code_information": [
        {
          "code": "3029301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 636,
          "minimum": 217.4261,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 424.6216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VITRECTOMY CENTURION",
      "code_information": [
        {
          "code": "3029308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1046.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH  82-151x",
      "code_information": [
        {
          "code": "3029345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1307,
          "minimum": 446.8174,
          "maximum": 948.4899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 872.6107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SMART STITCH PERFECT",
      "code_information": [
        {
          "code": "3029347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 917,
          "minimum": 265.8158,
          "maximum": 665.4669,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 612.2295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE           032401",
      "code_information": [
        {
          "code": "3029348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 396.4993,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-HEMA KNITTED   HGK75/75P",
      "code_information": [
        {
          "code": "3029426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1254,
          "minimum": 428.6985,
          "maximum": 7405.5837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 837.2256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-ACTIVA 2.5 INTELLIDOSE",
      "code_information": [
        {
          "code": "3029528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.1437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-DISPOSABLE  26-1221",
      "code_information": [
        {
          "code": "3029529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 2058.1261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1787.9506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORIENTATION 2307-71-000",
      "code_information": [
        {
          "code": "3029762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 721.3458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 663.6381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-NAVIGATION 6007-003-150",
      "code_information": [
        {
          "code": "3029767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 150.7031,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 624.2471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ARM ELEVATION 79-90500",
      "code_information": [
        {
          "code": "3029771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 520.5096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KNEE PROCEDURE TRACK 10712",
      "code_information": [
        {
          "code": "3029811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 180.7325,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 909.3311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-DEMAYO LEG 110550",
      "code_information": [
        {
          "code": "3029813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 533.856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.9843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BREAKAWAY GUIDE 2.5MM",
      "code_information": [
        {
          "code": "3029840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2605,
          "minimum": 603.9246,
          "maximum": 1890.4485,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1739.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144110",
      "code_information": [
        {
          "code": "3029841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1086,
          "minimum": 371.2652,
          "maximum": 788.1102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 725.0614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DHS GUIDE          900.723",
      "code_information": [
        {
          "code": "3029855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 658,
          "minimum": 224.9471,
          "maximum": 551.6512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 439.3098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-POSITIONING EZ CLIP 2MM",
      "code_information": [
        {
          "code": "3029858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1123,
          "minimum": 383.9142,
          "maximum": 1046.0241,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 749.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-FLUTED HEADLESS 7650-2038A",
      "code_information": [
        {
          "code": "3029885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1881,
          "minimum": 616.7149,
          "maximum": 1365.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1255.8384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE              357.399",
      "code_information": [
        {
          "code": "3029929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1109,
          "minimum": 379.1281,
          "maximum": 3924.9538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 740.4172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PINS-GUIDE 7.3         900.726",
      "code_information": [
        {
          "code": "3030050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 943,
          "minimum": 207.4253,
          "maximum": 684.3351,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 629.5883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1\\\"",
      "code_information": [
        {
          "code": "3033301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 48,
          "minimum": 16.4095,
          "maximum": 34.8336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 32.0469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 16FR 10ML",
      "code_information": [
        {
          "code": "3033303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F SCREWS 45-80040",
      "code_information": [
        {
          "code": "3033883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1582.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-LARGE SOFT       PCP40",
      "code_information": [
        {
          "code": "3033952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POINTER-TRACER         9733423",
      "code_information": [
        {
          "code": "3034140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3396,
          "minimum": 175.7276,
          "maximum": 2464.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2267.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-BIOPSY             AUR-BP",
      "code_information": [
        {
          "code": "3034190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 316,
          "minimum": 108.0293,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.9755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-GEL HAND            C8XX2",
      "code_information": [
        {
          "code": "3034194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2636.5262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOCATCH-II W/POUCH ALL 173's",
      "code_information": [
        {
          "code": "3034302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2140,
          "minimum": 497.7095,
          "maximum": 1552.998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1428.7582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD ENTERAL 7FR 350CM",
      "code_information": [
        {
          "code": "3034510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1046.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NEUROVISION M5   2012021",
      "code_information": [
        {
          "code": "3034522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 592.2465,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 2.3MM 6.9FR 300CM",
      "code_information": [
        {
          "code": "3034891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 8367.0806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-WOUND GELPOINT CNGL2",
      "code_information": [
        {
          "code": "3038330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 19421.7925,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2824.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-PAIN ONQ 400ML    PM028-A",
      "code_information": [
        {
          "code": "3038635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1884,
          "minimum": 644.0734,
          "maximum": 3289.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1257.8413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-KNOT 2-0 FIBERWIRE",
      "code_information": [
        {
          "code": "3038667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 99.5419,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-DEKNATEL 4.4      MDP-44",
      "code_information": [
        {
          "code": "3038930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 398,
          "minimum": 136.0622,
          "maximum": 525.5145,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 265.7223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GREEN    ECR45G",
      "code_information": [
        {
          "code": "3039881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1406,
          "minimum": 207.4253,
          "maximum": 1020.3342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 938.7075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO LINEAR       TR35B",
      "code_information": [
        {
          "code": "3039888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 838,
          "minimum": 47.2685,
          "maximum": 608.1366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 559.4857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-TUBING         RF10210",
      "code_information": [
        {
          "code": "3039889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 80.0784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W564",
      "code_information": [
        {
          "code": "3039894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 104.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W332",
      "code_information": [
        {
          "code": "3039896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 239.6791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN        XR30G",
      "code_information": [
        {
          "code": "3039899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 431,
          "minimum": 147.3438,
          "maximum": 312.7767,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH       170056",
      "code_information": [
        {
          "code": "3039902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 676.2176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 575.5091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-VASCULAR/THIN     TR45W",
      "code_information": [
        {
          "code": "3039909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 239.6791,
          "maximum": 882.4512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 811.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM              XR30B",
      "code_information": [
        {
          "code": "3039911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 431,
          "minimum": 147.3438,
          "maximum": 676.2176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STANDARD BLUE     6R45B",
      "code_information": [
        {
          "code": "3039912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 415.7077,
          "maximum": 944.8139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 811.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40B",
      "code_information": [
        {
          "code": "3039913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1699,
          "minimum": 277.4939,
          "maximum": 1232.9643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1134.3272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD- STAPLE TCR-55",
      "code_information": [
        {
          "code": "3039914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 499,
          "minimum": 170.5906,
          "maximum": 456.002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 333.1544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-LINEAR CUTTER    TCR-75",
      "code_information": [
        {
          "code": "3039916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 820,
          "minimum": 280.3292,
          "maximum": 944.8139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 547.4681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40G",
      "code_information": [
        {
          "code": "3039917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1699,
          "minimum": 580.8284,
          "maximum": 1232.9643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1134.3272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER    TCT75",
      "code_information": [
        {
          "code": "3039918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1465,
          "minimum": 285.8354,
          "maximum": 1063.1505,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 978.0985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO GIA 30/3.5  030452",
      "code_information": [
        {
          "code": "3039932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2061,
          "minimum": 704.5835,
          "maximum": 1495.6677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1376.0143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-CARIOTOMY        205",
      "code_information": [
        {
          "code": "3039975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 465,
          "minimum": 158.9672,
          "maximum": 6833.3568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 310.4545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-DISP FILTRA 04259",
      "code_information": [
        {
          "code": "3039981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 7440.618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 390.5717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-OMMAYA    NL850-121x",
      "code_information": [
        {
          "code": "3040439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3043,
          "minimum": 170.1666,
          "maximum": 2208.3051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2031.6407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-C-SECTION DISP G6314",
      "code_information": [
        {
          "code": "3040500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 281.6966,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 550.1387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND          C8404",
      "code_information": [
        {
          "code": "3040501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 281.6966,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 550.1387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEXOR TENDON",
      "code_information": [
        {
          "code": "3040509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 600.588,
          "maximum": 1943.4246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1787.9506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-LONESTAR        3304",
      "code_information": [
        {
          "code": "3040511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1080,
          "minimum": 369.214,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 721.0555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ORTHO ALEXIS   HR004",
      "code_information": [
        {
          "code": "3040513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1611,
          "minimum": 310.3038,
          "maximum": 1169.1027,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1075.5745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE        013593",
      "code_information": [
        {
          "code": "3040518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 190.7606,
          "maximum": 761.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 372.5454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-SURGICAL RING   3715",
      "code_information": [
        {
          "code": "3040521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1370,
          "minimum": 415.4067,
          "maximum": 994.209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 914.6723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-LOOPED 3 PRONG  5030",
      "code_information": [
        {
          "code": "3040525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 498.7301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND LG       C8303",
      "code_information": [
        {
          "code": "3040527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND MEDIUM   C8302",
      "code_information": [
        {
          "code": "3040530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XL       C8304",
      "code_information": [
        {
          "code": "3040532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 239.123,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 550.1387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND SMALL    C8301",
      "code_information": [
        {
          "code": "3040533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XSMALL   C8312",
      "code_information": [
        {
          "code": "3040534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-MALYUGIN ALL SZS MAL-000x",
      "code_information": [
        {
          "code": "3040661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1565,
          "minimum": 535.0185,
          "maximum": 2728.2266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1044.8629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.8 CANN DRI",
      "code_information": [
        {
          "code": "3040704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 1301.8301,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1143.0065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-2.0X7          AR-7200S",
      "code_information": [
        {
          "code": "3044850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 827,
          "minimum": 282.7222,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 552.1416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 2.3 BIPOLAR",
      "code_information": [
        {
          "code": "3044897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2785,
          "minimum": 952.0936,
          "maximum": 2021.0745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1859.3885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS MALLEABLE BI",
      "code_information": [
        {
          "code": "3044899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3215,
          "minimum": 336.9966,
          "maximum": 2333.1255,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2146.4755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION ANSPACH 111613",
      "code_information": [
        {
          "code": "3044922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 966,
          "minimum": 255.806,
          "maximum": 701.0262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 644.9441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68HP ALL",
      "code_information": [
        {
          "code": "3049715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRI PORT III PAL 303LS",
      "code_information": [
        {
          "code": "3050004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 580.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 4.0X170 144170",
      "code_information": [
        {
          "code": "3050009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 630.9236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CELLEBRITY CYTOLOGY",
      "code_information": [
        {
          "code": "3050015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 234,
          "minimum": 79.9964,
          "maximum": 4265.287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 156.2287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATIR SM DISP 13MM",
      "code_information": [
        {
          "code": "3055843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 833.5939,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 131.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 2ML 1506078",
      "code_information": [
        {
          "code": "3055845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1499,
          "minimum": 512.4554,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1000.7984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL ALL SZS 456.30Xs",
      "code_information": [
        {
          "code": "3055898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3677,
          "minimum": 1233.9859,
          "maximum": 2668.3989,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2454.927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MISTY NEB W/FILTER",
      "code_information": [
        {
          "code": "3058511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 607.2612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-HELIOCOIDAL RASP 3.2MM",
      "code_information": [
        {
          "code": "3058512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1092,
          "minimum": 373.3164,
          "maximum": 995.9751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 729.0672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONE MILL DISP",
      "code_information": [
        {
          "code": "3058513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1791,
          "minimum": 262.4792,
          "maximum": 1299.7287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1195.7504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-CORE IRRIGATION",
      "code_information": [
        {
          "code": "3058514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 472,
          "minimum": 161.3602,
          "maximum": 605.5929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 315.128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 2.3MM",
      "code_information": [
        {
          "code": "3058515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1089,
          "minimum": 372.2908,
          "maximum": 790.2873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 727.0643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-SOFT TOUCH RND FLUTED ALL",
      "code_information": [
        {
          "code": "3058516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND ALL SIZES",
      "code_information": [
        {
          "code": "3058517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 436.5614,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 852.5814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND COURSE ALL",
      "code_information": [
        {
          "code": "3058518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 3.0MM",
      "code_information": [
        {
          "code": "3058521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1089,
          "minimum": 372.2908,
          "maximum": 790.2873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 727.0643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CUTTING DIAMOND 25.4X0.8",
      "code_information": [
        {
          "code": "3058522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1042,
          "minimum": 356.2232,
          "maximum": 862.5111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 695.685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 310.23S",
      "code_information": [
        {
          "code": "3058526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1551,
          "minimum": 530.2324,
          "maximum": 1125.5607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1035.5158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 02.7 CSS-072-27",
      "code_information": [
        {
          "code": "3058530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1347,
          "minimum": 460.492,
          "maximum": 977.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 899.3165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110 143110",
      "code_information": [
        {
          "code": "3058543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 683,
          "minimum": 233.4937,
          "maximum": 495.6531,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 456.0009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EPIDURAL 117\\\" INF 1633902",
      "code_information": [
        {
          "code": "3058611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 689.0079,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE 10X5",
      "code_information": [
        {
          "code": "3058612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1239,
          "minimum": 423.5706,
          "maximum": 1157.2441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 827.2109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-FLOW 50 COBLATION",
      "code_information": [
        {
          "code": "3058620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1833,
          "minimum": 626.6383,
          "maximum": 1330.2081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1223.7915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ACCOMINIZER 4.0",
      "code_information": [
        {
          "code": "3058623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 531.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 295.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STONCUTTER 5.5 7205331",
      "code_information": [
        {
          "code": "3058624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 956,
          "minimum": 279.1622,
          "maximum": 693.7692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 638.2677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3058625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4.0 1864G",
      "code_information": [
        {
          "code": "3058639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 14474.7269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.4115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL FLEX MED 27MM",
      "code_information": [
        {
          "code": "3058643",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 523.2901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.8142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-RETRIEVAL 30MM DGN-538-5",
      "code_information": [
        {
          "code": "3058644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 941,
          "minimum": 321.6948,
          "maximum": 682.8837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 628.253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 2.0MM 5820-010-020",
      "code_information": [
        {
          "code": "3058655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1105,
          "minimum": 377.7607,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 737.7466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARTHREX ANGEL BMC",
      "code_information": [
        {
          "code": "3058674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDO FEEDING 12FR X 60”",
      "code_information": [
        {
          "code": "3058693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 252.3694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MINI 4.0 283459",
      "code_information": [
        {
          "code": "3058696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1275,
          "minimum": 435.8777,
          "maximum": 925.2675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 851.2461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 FULL RADIUS",
      "code_information": [
        {
          "code": "3058697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1275,
          "minimum": 435.8777,
          "maximum": 925.2675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 851.2461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 018 14MMX34CM",
      "code_information": [
        {
          "code": "3058707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 877.5258,
          "maximum": 3070.4367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2824.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-240",
      "code_information": [
        {
          "code": "3058716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1082,
          "minimum": 369.8978,
          "maximum": 785.2074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 722.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANOSCOPE-BEVELED DISP 103X18M",
      "code_information": [
        {
          "code": "3058720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 16442.2087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-EXPEL NEPHR I/E 8.3/22",
      "code_information": [
        {
          "code": "3058729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1262,
          "minimum": 431.4335,
          "maximum": 915.8334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 842.5667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH 15FR 71C",
      "code_information": [
        {
          "code": "3058737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 7838.7856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-VPAD 2 INS-0050",
      "code_information": [
        {
          "code": "3058749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2207,
          "minimum": 754.4957,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1473.4903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-ALWAYS ON TIP INS-0352",
      "code_information": [
        {
          "code": "3058751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1948.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-19 GA ANSO INS-0382",
      "code_information": [
        {
          "code": "3058752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1948.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GA ANSO INS 0392",
      "code_information": [
        {
          "code": "3058753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1948.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GA NITINOL INS-5410",
      "code_information": [
        {
          "code": "3058754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4175,
          "minimum": 1227.3127,
          "maximum": 3029.7975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2787.4137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 8MMX24CM",
      "code_information": [
        {
          "code": "3058757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 6MMX17CM",
      "code_information": [
        {
          "code": "3058758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 8523.9008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE DISTRACTOR DISP",
      "code_information": [
        {
          "code": "3058766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 192.8118,
          "maximum": 935.3602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 376.5512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 4MMX7CM",
      "code_information": [
        {
          "code": "3058776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MM X xCM",
      "code_information": [
        {
          "code": "3058777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 32205.4193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 AR 8943-16",
      "code_information": [
        {
          "code": "3058786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1013,
          "minimum": 346.3091,
          "maximum": 2388.4495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.3234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPIN EWC BIOPSY GUIDE",
      "code_information": [
        {
          "code": "3058788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3127,
          "minimum": 1069.0114,
          "maximum": 3022.4035,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2087.7228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DISP SHOULDER 1.8MM",
      "code_information": [
        {
          "code": "3058805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1659,
          "minimum": 567.1538,
          "maximum": 1455.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1107.6214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENTRAINER-AIR RT008",
      "code_information": [
        {
          "code": "3058809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.1026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 5.0 5050",
      "code_information": [
        {
          "code": "3058819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58043,
          "minimum": 19842.8621,
          "maximum": 42121.8051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38752.0607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 7.0 7050",
      "code_information": [
        {
          "code": "3058820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60044,
          "minimum": 99.5419,
          "maximum": 43573.9308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40088.0163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 BV-1 M8709",
      "code_information": [
        {
          "code": "3058836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 498.7301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 6MM X xxCM",
      "code_information": [
        {
          "code": "3058840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 2MMXxxCM",
      "code_information": [
        {
          "code": "3058843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4220,
          "minimum": 1442.6697,
          "maximum": 3062.454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2817.4577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX20CM",
      "code_information": [
        {
          "code": "3058844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5064,
          "minimum": 1731.2037,
          "maximum": 3674.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3380.9492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX30CM",
      "code_information": [
        {
          "code": "3058845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5591,
          "minimum": 1911.3664,
          "maximum": 4057.3887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3732.7976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 CX ALL",
      "code_information": [
        {
          "code": "3058847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HEATED AIRVO 900PT501",
      "code_information": [
        {
          "code": "3058860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 181.8447,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO SM OPT942",
      "code_information": [
        {
          "code": "3058861",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.3196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO MED OPT944",
      "code_information": [
        {
          "code": "3058862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.3196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO LARGE OPT946",
      "code_information": [
        {
          "code": "3058863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 86.1955,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.3196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-013-000 SZ4",
      "code_information": [
        {
          "code": "3058864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HEALING W/PLUG 30MM 95084",
      "code_information": [
        {
          "code": "3058868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 42.8197,
          "maximum": 156.7512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.5MM",
      "code_information": [
        {
          "code": "3058875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CONTOUR CERVICAL 13-15",
      "code_information": [
        {
          "code": "3058876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 61.7271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.4115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-RIB UNIVERSAL 8” MALE",
      "code_information": [
        {
          "code": "3058877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.2587,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3.0 1893G",
      "code_information": [
        {
          "code": "3058878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 66.1759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MMX15CM",
      "code_information": [
        {
          "code": "3058884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 129.5713,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SLIM MED",
      "code_information": [
        {
          "code": "3058885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 79.6545,
          "maximum": 216.3229,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 155.5611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-SYSTEM UA2007",
      "code_information": [
        {
          "code": "3058887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 162,
          "minimum": 55.3821,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 108.1583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WATER SUCTION BIOPSY VALVE",
      "code_information": [
        {
          "code": "3058903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.7937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-ACCUSTAT 125NM S 801015",
      "code_information": [
        {
          "code": "3058929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5081,
          "minimum": 280.8305,
          "maximum": 3687.2817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3392.2992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MIDLINE 5FR BIO FLO",
      "code_information": [
        {
          "code": "3058932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 1.4X27MM",
      "code_information": [
        {
          "code": "3058955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3358,
          "minimum": 1147.9822,
          "maximum": 12836.4563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2241.9486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON,CAPIOX HPH-1000",
      "code_information": [
        {
          "code": "3058981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 291.2689,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 568.8327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOBLADE GASTRO",
      "code_information": [
        {
          "code": "3058983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5049,
          "minimum": 522.734,
          "maximum": 3664.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3370.9346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORTHOLOCK 3X110MM EX",
      "code_information": [
        {
          "code": "3058990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 319.6436,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 624.2471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X 343MM",
      "code_information": [
        {
          "code": "3058991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1159,
          "minimum": 396.2214,
          "maximum": 841.0863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 773.7994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y935H",
      "code_information": [
        {
          "code": "3059006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.0X40X91MM",
      "code_information": [
        {
          "code": "3059015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.6792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-GENESYS HTA M006580211",
      "code_information": [
        {
          "code": "3059026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6769,
          "minimum": 870.8526,
          "maximum": 4912.2633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4519.2822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-CLEANING STICK 900PT602",
      "code_information": [
        {
          "code": "3059061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 93.4248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.4115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-QUADFUSE 9” EXT SMALLBORE",
      "code_information": [
        {
          "code": "3059062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 1661.0707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.1642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED OPT316",
      "code_information": [
        {
          "code": "3059066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 522,
          "minimum": 178.4535,
          "maximum": 401.5042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 348.5102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-HEADREST SOFTOUCH",
      "code_information": [
        {
          "code": "3059127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 12074.0432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.4555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ESOPHYX TIF R2007",
      "code_information": [
        {
          "code": "3059129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21712,
          "minimum": 1866.2716,
          "maximum": 15756.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14495.8865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTER CONNECT PT-5558-F",
      "code_information": [
        {
          "code": "3059131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 722.93,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.0704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 3.5X195 700353",
      "code_information": [
        {
          "code": "3059137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1228,
          "minimum": 419.81,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 819.8668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACQUIRE EUS FND",
      "code_information": [
        {
          "code": "3059156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 497.7095,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1769.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 2.0MM BIT",
      "code_information": [
        {
          "code": "3059170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2114,
          "minimum": 279.1622,
          "maximum": 1534.1298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1411.3994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-IMPLANT SIZING SG - x",
      "code_information": [
        {
          "code": "3059171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 6595.346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIALYZER-HIGH FLUX 1.6 720DH16",
      "code_information": [
        {
          "code": "3059177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 859.1745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ULTRAPERC FULL 100/573/000",
      "code_information": [
        {
          "code": "3059178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1545,
          "minimum": 30.5855,
          "maximum": 1121.2065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1031.51,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT MED",
      "code_information": [
        {
          "code": "3059179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 2180.4681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENVEO PRO LOADING",
      "code_information": [
        {
          "code": "3059185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2618,
          "minimum": 255.806,
          "maximum": 1899.8826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1747.892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 1.5MM NEEDLES",
      "code_information": [
        {
          "code": "3059187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 460,
          "minimum": 157.2578,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 307.1162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-VERTEX DRILL 2.4MM",
      "code_information": [
        {
          "code": "3059197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 18503.6714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN 5X5CM FUD021",
      "code_information": [
        {
          "code": "3059209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-KNOTLESS S-TAK STEP 3MM",
      "code_information": [
        {
          "code": "3059213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.4055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW OSC SAGITTAL xxMM",
      "code_information": [
        {
          "code": "3059220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 8367.0806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 416.6099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO DURACLIP 235CM 11MM",
      "code_information": [
        {
          "code": "3059232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 16632.951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 941.378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT LG",
      "code_information": [
        {
          "code": "3059245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 39.9135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT SM",
      "code_information": [
        {
          "code": "3059246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 2632.0213,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-POLAR COMBO 1232PP",
      "code_information": [
        {
          "code": "3059252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 907,
          "minimum": 310.0714,
          "maximum": 780.2083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 605.5531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-TRI STAPLE 2.0 SIG30AVM",
      "code_information": [
        {
          "code": "3059259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2871,
          "minimum": 981.494,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1916.8059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND 1.0MM",
      "code_information": [
        {
          "code": "3059273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 151.2592,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 852.5814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION MED",
      "code_information": [
        {
          "code": "3059281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 279,
          "minimum": 95.3803,
          "maximum": 4504.9661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.2727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 15\\\" ADJ ILIO",
      "code_information": [
        {
          "code": "3059288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 328,
          "minimum": 112.1317,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.9872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP ALL",
      "code_information": [
        {
          "code": "3059603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 2352.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT 111645",
      "code_information": [
        {
          "code": "3059922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 266.3127,
          "maximum": 664.5395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 520.0947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X140 143140",
      "code_information": [
        {
          "code": "3059924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1195,
          "minimum": 408.5285,
          "maximum": 2945.1056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 797.8346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ABC SINGLE FUNCTION",
      "code_information": [
        {
          "code": "3059973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 850,
          "minimum": 290.5851,
          "maximum": 726.2666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 567.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATCHER-STONE WITH TUB 840-750",
      "code_information": [
        {
          "code": "3059984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 825,
          "minimum": 282.0385,
          "maximum": 4179.6476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 550.8063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP       7-382",
      "code_information": [
        {
          "code": "3059989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 6650.3999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ISOLATOR  BIP   OSL2",
      "code_information": [
        {
          "code": "3059996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11959,
          "minimum": 627.8369,
          "maximum": 8678.6463,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7984.3546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-LINEAR 60GRN      TX60G",
      "code_information": [
        {
          "code": "3060001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 913,
          "minimum": 305.855,
          "maximum": 662.5641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 609.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM GREEN        XR60G",
      "code_information": [
        {
          "code": "3060002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 550,
          "minimum": 84.5272,
          "maximum": 399.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 367.2042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE   RC014MIBB",
      "code_information": [
        {
          "code": "3060082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 68.9564,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 624.2471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CORONARY PERFUSN 10004",
      "code_information": [
        {
          "code": "3060083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 477.1338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.7879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEX IRIS     611.75",
      "code_information": [
        {
          "code": "3060129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 858,
          "minimum": 175.1715,
          "maximum": 622.6506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 572.8386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 8\\\"  7708-000-10",
      "code_information": [
        {
          "code": "3060132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 228.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.3079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VESSEL           30003",
      "code_information": [
        {
          "code": "3060134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 101,
          "minimum": 34.5284,
          "maximum": 1063.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 67.432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-T-TUBE 16FR       0099830",
      "code_information": [
        {
          "code": "3060199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 825.2524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE MEDIUM   9893",
      "code_information": [
        {
          "code": "3060289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 170.2487,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 332.4867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-UNIV     60-6010-001",
      "code_information": [
        {
          "code": "3060315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 68.9564,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 360.5278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERZ-REFLECTIVE PK   PM 8005",
      "code_information": [
        {
          "code": "3060317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 143.4738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.7879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-SPRING CLIP 6MM  CSOFT6",
      "code_information": [
        {
          "code": "3060318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.2522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-SILVERSTEIN PK 1428010",
      "code_information": [
        {
          "code": "3060385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 71.4498,
          "maximum": 12457.1961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 139.5376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0 CT-2 Z332H",
      "code_information": [
        {
          "code": "3060417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.1378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROGRAMMER-TEST STIM 3531",
      "code_information": [
        {
          "code": "3060442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2604,
          "minimum": 259.1426,
          "maximum": 1889.7228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1738.545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MINI HOOK 357501",
      "code_information": [
        {
          "code": "3060443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 414.2945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 311.1221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 4.0MM 03.000.012S",
      "code_information": [
        {
          "code": "3060451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 745,
          "minimum": 254.6893,
          "maximum": 540.6465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 497.3948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 5.0MM 03.000.015S",
      "code_information": [
        {
          "code": "3060452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 360.5278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90X9.5 05.003.126S",
      "code_information": [
        {
          "code": "3060455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 1953.0232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 416.6099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 10M",
      "code_information": [
        {
          "code": "3060460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3512,
          "minimum": 398.1676,
          "maximum": 2548.6584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2344.7657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT",
      "code_information": [
        {
          "code": "3060472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 5MM PAL-508LL",
      "code_information": [
        {
          "code": "3060475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 1614.9144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 494.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-FAST FIX 360 KPSC",
      "code_information": [
        {
          "code": "3060478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1344,
          "minimum": 459.4664,
          "maximum": 975.3408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 897.3135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU RIGHT 7210424",
      "code_information": [
        {
          "code": "3060485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1334,
          "minimum": 456.0477,
          "maximum": 968.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 890.6371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU LEFT 7210423",
      "code_information": [
        {
          "code": "3060486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 864.599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STRT 7210426",
      "code_information": [
        {
          "code": "3060488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 864.599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.3MM CROSSPIN 62-23333",
      "code_information": [
        {
          "code": "3060489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STR 7210425",
      "code_information": [
        {
          "code": "3060494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 909.3021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 836.5579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SILICONE 8CM        205108",
      "code_information": [
        {
          "code": "3061090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1750,
          "minimum": 598.2635,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1168.377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-SINGLE HOLE 1877-01-010",
      "code_information": [
        {
          "code": "3062492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2040,
          "minimum": 95.6492,
          "maximum": 1480.428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1361.9938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-3' EPV100 VENT",
      "code_information": [
        {
          "code": "3068320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.8348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX PEDS MAXP",
      "code_information": [
        {
          "code": "3068323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 283.0549,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP VIBRATORY ACAPELLA",
      "code_information": [
        {
          "code": "3068325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 509,
          "minimum": 31.6977,
          "maximum": 369.3813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 339.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED W/7' TUBING",
      "code_information": [
        {
          "code": "3068327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 199.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BIPAP PERFORMATRAK LARGE",
      "code_information": [
        {
          "code": "3068330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 35.5904,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT DUAL LIMB",
      "code_information": [
        {
          "code": "3068331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT CAPNOXYGEN C02-01",
      "code_information": [
        {
          "code": "3068332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 102.3224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT/PED 8’ 58051",
      "code_information": [
        {
          "code": "3068333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.8465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-MYOSURE            40-902",
      "code_information": [
        {
          "code": "3078533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 171,
          "minimum": 58.4589,
          "maximum": 3316.5804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.1671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-DURA           20-xxxx",
      "code_information": [
        {
          "code": "3078541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5964,
          "minimum": 398.1676,
          "maximum": 4328.0748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3981.8288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-DURAL           1314",
      "code_information": [
        {
          "code": "3078593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 868.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH INDWELLING SLIT 295-6",
      "code_information": [
        {
          "code": "3078730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 1133.5434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1042.8599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-KARLEN BALLOON    CS-01700",
      "code_information": [
        {
          "code": "3078823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 207.4253,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML 0797208",
      "code_information": [
        {
          "code": "3078850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 276.3817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.8846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU, DIALYSIS 2.5% 2L 5B9876",
      "code_information": [
        {
          "code": "3078852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 497,
          "minimum": 28.3611,
          "maximum": 360.6729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 331.8191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML  07138-09",
      "code_information": [
        {
          "code": "3078858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 51,
          "minimum": 17.4351,
          "maximum": 865.8477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 34.0498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK E3773-45C",
      "code_information": [
        {
          "code": "3078982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1254,
          "minimum": 428.6985,
          "maximum": 1022.6679,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 837.2256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MAS TLIF LIGHT   3400033",
      "code_information": [
        {
          "code": "3079040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 636.1784,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1904.7883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MULTILEAD TRIAL     3013",
      "code_information": [
        {
          "code": "3079055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1144,
          "minimum": 391.0934,
          "maximum": 830.2008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 763.7847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.0X13        AR-8400EX",
      "code_information": [
        {
          "code": "3079215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 330.1935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.-X13 AR-8500EX",
      "code_information": [
        {
          "code": "3079228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.1104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER        20400161S/10",
      "code_information": [
        {
          "code": "3079240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 306,
          "minimum": 99.5419,
          "maximum": 222.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 204.2991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL G2 TIP 35CM",
      "code_information": [
        {
          "code": "3079250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3329,
          "minimum": 364.8016,
          "maximum": 2415.8553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2222.5869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 ABRADER    72201518",
      "code_information": [
        {
          "code": "3079252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 656,
          "minimum": 224.2633,
          "maximum": 476.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 437.9745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR    72201513",
      "code_information": [
        {
          "code": "3079253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 637,
          "minimum": 217.7679,
          "maximum": 462.2709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 425.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3079254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 598,
          "minimum": 204.4352,
          "maximum": 433.9686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 399.2511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5 FULL RADIUS 7205305",
      "code_information": [
        {
          "code": "3079257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 498.2656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 FULL RADIUM 7205306",
      "code_information": [
        {
          "code": "3079261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 295.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 INCISOR     7205345",
      "code_information": [
        {
          "code": "3079262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 1761.1687,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 295.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL 45CM    NSLG2C45A",
      "code_information": [
        {
          "code": "3079282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3167,
          "minimum": 1082.686,
          "maximum": 2298.2919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2114.4285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 36\\\"   HAR36",
      "code_information": [
        {
          "code": "3079285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3146,
          "minimum": 1075.5068,
          "maximum": 2283.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2100.408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HS FOCUS 9CM CRVD  HAR9F",
      "code_information": [
        {
          "code": "3079290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2871,
          "minimum": 680.1103,
          "maximum": 2083.4847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1916.8059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INPUT 8FR PS    080011",
      "code_information": [
        {
          "code": "3079468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 425.9726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNLER SM-LG    9009-s",
      "code_information": [
        {
          "code": "3079475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 766,
          "minimum": 261.8685,
          "maximum": 555.8862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 511.4153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-RENAL 20CM      900-123",
      "code_information": [
        {
          "code": "3079482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 313.5024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 288.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-EXT BILATERAL DYNJP8004A",
      "code_information": [
        {
          "code": "3079499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 2033.1016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-CORNEAL DISP      E5699",
      "code_information": [
        {
          "code": "3079626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-CAROTID ALL     2000-00s",
      "code_information": [
        {
          "code": "3079680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 6136.0074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909504",
      "code_information": [
        {
          "code": "3079703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11962,
          "minimum": 2091.4921,
          "maximum": 8680.8234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7986.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5070",
      "code_information": [
        {
          "code": "3079707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3761,
          "minimum": 1285.7537,
          "maximum": 2729.3577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2511.0091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5071",
      "code_information": [
        {
          "code": "3079709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3761,
          "minimum": 1285.7537,
          "maximum": 11631.3876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2511.0091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PHACO .9MM  8065-750517",
      "code_information": [
        {
          "code": "3079736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 429,
          "minimum": 146.66,
          "maximum": 7567.9649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 286.4193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SMALL VIT PLUS 1",
      "code_information": [
        {
          "code": "3079745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1675,
          "minimum": 572.6236,
          "maximum": 7567.9649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1118.3037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STAR            AR-1606",
      "code_information": [
        {
          "code": "3079766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 877,
          "minimum": 299.8155,
          "maximum": 636.4389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 585.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 12MM        CB12LT",
      "code_information": [
        {
          "code": "3079770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1106,
          "minimum": 378.1025,
          "maximum": 8681.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 738.4143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM KII          CFS22",
      "code_information": [
        {
          "code": "3079789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.5347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-FIBER          AR-7209SN",
      "code_information": [
        {
          "code": "3079790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 80.0784,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.4055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM KII           CFS02",
      "code_information": [
        {
          "code": "3079791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 114.5566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM THREADED KII CTS22",
      "code_information": [
        {
          "code": "3079792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.5347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM THREADED KII  CTS0S",
      "code_information": [
        {
          "code": "3079793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 165.1617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.8113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATABLE OVAL",
      "code_information": [
        {
          "code": "3079795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 297,
          "minimum": 101.5339,
          "maximum": 8681.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.2903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SILICONE         400561",
      "code_information": [
        {
          "code": "3079975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 550,
          "minimum": 188.0257,
          "maximum": 399.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 367.2042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER MINI        1500",
      "code_information": [
        {
          "code": "3079992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 425.9859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 391.907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER SMALL       1500",
      "code_information": [
        {
          "code": "3079994",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 554,
          "minimum": 189.3931,
          "maximum": 402.0378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 369.8748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER PETITE      1500",
      "code_information": [
        {
          "code": "3079996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 8572.8376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 391.907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-AGGRESSIVE 3.5   283315",
      "code_information": [
        {
          "code": "3080062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 382.56,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ULTRA AGGRESSIVE 283325",
      "code_information": [
        {
          "code": "3080067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 1213.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 382.56,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.5MM AR-1204AS-95",
      "code_information": [
        {
          "code": "3080073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2182,
          "minimum": 745.9491,
          "maximum": 1583.4774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1456.7992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 10MM AR-1204AS-100",
      "code_information": [
        {
          "code": "3080074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1582.7517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1456.1316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.0MM AR1204AS90",
      "code_information": [
        {
          "code": "3080075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1819,
          "minimum": 207.4253,
          "maximum": 1320.0483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1214.4444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-OPTIMOLD NASAL   PS1688",
      "code_information": [
        {
          "code": "3080204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 195.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 81.4526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3080355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 352,
          "minimum": 113.4444,
          "maximum": 255.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 235.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-EGIA 60 MED   EGIA60AVM",
      "code_information": [
        {
          "code": "3080925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 477.6899,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1046.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-ENDOCLIP MULTI    ER320",
      "code_information": [
        {
          "code": "3080932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 859,
          "minimum": 293.6619,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 573.5062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR VASCULAR  TX30V",
      "code_information": [
        {
          "code": "3081085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 81.7467,
          "maximum": 697.3977,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 641.6059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT 12”",
      "code_information": [
        {
          "code": "3081101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.1437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT RIGHT",
      "code_information": [
        {
          "code": "3081102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.1437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY RT ANGLE Y PORT 12”",
      "code_information": [
        {
          "code": "3081103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 117.8932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.1437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIEDER TS101DC",
      "code_information": [
        {
          "code": "3081129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 594,
          "minimum": 203.0677,
          "maximum": 5771.7619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 396.5805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-POLYSORB 55      SZ 200",
      "code_information": [
        {
          "code": "3081173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4940,
          "minimum": 497.1534,
          "maximum": 3584.958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3298.1614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN INSORB 2030",
      "code_information": [
        {
          "code": "3081400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 894,
          "minimum": 305.6272,
          "maximum": 4780.7917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 596.8737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZS ECS's",
      "code_information": [
        {
          "code": "3081408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1763,
          "minimum": 602.7077,
          "maximum": 4780.7917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1177.0564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZ CDHxxA",
      "code_information": [
        {
          "code": "3081415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1570,
          "minimum": 536.7278,
          "maximum": 1451.9771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1048.2011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWER  PLEE60A",
      "code_information": [
        {
          "code": "3081416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2611,
          "minimum": 892.6091,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1743.2185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-INTERNAL EEA   EEAXL25",
      "code_information": [
        {
          "code": "3081425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1376.3475,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWERED PCE60A",
      "code_information": [
        {
          "code": "3081432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2475,
          "minimum": 846.1155,
          "maximum": 1796.1075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1652.4189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 45       EC45A",
      "code_information": [
        {
          "code": "3081433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2038,
          "minimum": 696.7206,
          "maximum": 1478.9766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1360.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 60       EC60A",
      "code_information": [
        {
          "code": "3081436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2635,
          "minimum": 900.8139,
          "maximum": 1912.2195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1759.2419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-EGIA HANDLE  EGIAUSTND",
      "code_information": [
        {
          "code": "3081443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2985,
          "minimum": 1020.4666,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1992.9173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDO GIA UNIVER 030449",
      "code_information": [
        {
          "code": "3081491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 464.8996,
          "maximum": 1915.848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1762.5802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-THICK TISSUE      TRT75",
      "code_information": [
        {
          "code": "3081494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3752.0067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 558.1504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3081502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 61.171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT STR 35WD",
      "code_information": [
        {
          "code": "3081503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.4408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAYS-SURGICAL PACK    3311-8G",
      "code_information": [
        {
          "code": "3081506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER   TLC-75",
      "code_information": [
        {
          "code": "3081530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 60BL      TX60B",
      "code_information": [
        {
          "code": "3081535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 904,
          "minimum": 309.0458,
          "maximum": 1678.8659,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR  40B     CS40B",
      "code_information": [
        {
          "code": "3081542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3019,
          "minimum": 1032.09,
          "maximum": 2190.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2015.6172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40G      CS40G",
      "code_information": [
        {
          "code": "3081544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3019,
          "minimum": 1032.09,
          "maximum": 2190.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2015.6172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDOPATH VASC PVE35A",
      "code_information": [
        {
          "code": "3081550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2231,
          "minimum": 762.7005,
          "maximum": 1619.0367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1489.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-HEAVY WIRE 90    TLH90",
      "code_information": [
        {
          "code": "3081554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 791,
          "minimum": 270.4151,
          "maximum": 574.0287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 528.1064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3081569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 12302.6003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A28-2",
      "code_information": [
        {
          "code": "3082047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21603,
          "minimum": 7385.3066,
          "maximum": 15677.2971,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14423.1133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A25-25",
      "code_information": [
        {
          "code": "3082066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21603,
          "minimum": 7385.3066,
          "maximum": 15677.2971,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14423.1133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-AAA MAIN    ETCF3636C49E",
      "code_information": [
        {
          "code": "3082068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 20042,
          "minimum": 6851.6555,
          "maximum": 14544.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 13380.921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STICK-FIBER            AR-7209",
      "code_information": [
        {
          "code": "3082089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 27356.7834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKINETTE-BARRIER   NON22535",
      "code_information": [
        {
          "code": "3082135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 366.4699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE FOOT        014407",
      "code_information": [
        {
          "code": "3082217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 659,
          "minimum": 225.2889,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 439.9774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRAIGHT           1123",
      "code_information": [
        {
          "code": "3082330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 198.8418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.9345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUMP-PERICARDIAL 1/4 CONNECTOR",
      "code_information": [
        {
          "code": "3082395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 164.6056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURG-STRIP 1/2X6       80-1451",
      "code_information": [
        {
          "code": "3082416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 296,
          "minimum": 101.192,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 197.6226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPRALOOP-BRUCKER/MESSROGHLI",
      "code_information": [
        {
          "code": "3082421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1727,
          "minimum": 498.2656,
          "maximum": 1253.2839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1153.0212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-NUKNITT 3X4      1943",
      "code_information": [
        {
          "code": "3082430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 598.209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC-0       173024",
      "code_information": [
        {
          "code": "3082450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 625.5534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 575.5091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC 2-0 173023",
      "code_information": [
        {
          "code": "3082453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 207.4253,
          "maximum": 625.5534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 575.5091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 698G",
      "code_information": [
        {
          "code": "3082542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 235.2303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-GORETEX CV-3      3N06A",
      "code_information": [
        {
          "code": "3082544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 423,
          "minimum": 144.6088,
          "maximum": 306.9711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 282.4134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J947H",
      "code_information": [
        {
          "code": "3082558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 4065.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONO PDSII        Z740D",
      "code_information": [
        {
          "code": "3082562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 305,
          "minimum": 104.2688,
          "maximum": 221.3385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 203.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ALIANCE        5060-05",
      "code_information": [
        {
          "code": "3082566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 1441.4112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.6989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-FLOSEAL 10ML   1503352",
      "code_information": [
        {
          "code": "3082592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2592,
          "minimum": 886.1137,
          "maximum": 5547.0975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1730.5332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING NEMA   3730ANS",
      "code_information": [
        {
          "code": "3082996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2636.5262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ACCESSORY           502",
      "code_information": [
        {
          "code": "3083003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4011,
          "minimum": 1371.22,
          "maximum": 2910.7827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2677.9201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BIOGLUE 5ML  BG3515-5US",
      "code_information": [
        {
          "code": "3083007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5122,
          "minimum": 760.7448,
          "maximum": 3717.0354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3419.6726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANS CATH 10\\\" PM040-A",
      "code_information": [
        {
          "code": "3083014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1368,
          "minimum": 467.6711,
          "maximum": 992.7576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 913.337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-CYSTO 25X5/8  581610",
      "code_information": [
        {
          "code": "3083019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 50,
          "minimum": 17.0932,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 33.3822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE VNUS        CFP",
      "code_information": [
        {
          "code": "3083021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION CATH  PM010-A",
      "code_information": [
        {
          "code": "3083022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 435,
          "minimum": 148.7112,
          "maximum": 333.1039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 290.4251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION 5\\\"    PM020-A",
      "code_information": [
        {
          "code": "3083023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 399.9188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-COLLECTION   003984-901",
      "code_information": [
        {
          "code": "3083083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 69.7404,
          "maximum": 867.516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.1994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-STERIDRAPE 8 7/8   1075",
      "code_information": [
        {
          "code": "3083104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 832.4817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URETERAL DIAL   240-100",
      "code_information": [
        {
          "code": "3083141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1497,
          "minimum": 511.7717,
          "maximum": 1086.3729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 999.4631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-PROTACK DEVICE 5MM",
      "code_information": [
        {
          "code": "3083191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3464,
          "minimum": 331.4356,
          "maximum": 2513.8248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2312.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB AR-13226",
      "code_information": [
        {
          "code": "3083200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 596,
          "minimum": 203.7515,
          "maximum": 575.5635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 397.9158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-BONE SCREW 3.5X50  311.349",
      "code_information": [
        {
          "code": "3083203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 1343.5376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.35 2883-02-043",
      "code_information": [
        {
          "code": "3083212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 522.734,
          "maximum": 1753.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1613.0279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-IQ DISPOSABLE 72-1010",
      "code_information": [
        {
          "code": "3083214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 310.8599,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 627.5854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-TVT DEVICE .5\\\"X18\\\" 810041",
      "code_information": [
        {
          "code": "3083229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5520.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-          AR-7237-7T",
      "code_information": [
        {
          "code": "3083486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 520,
          "minimum": 177.7697,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 347.1749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS2",
      "code_information": [
        {
          "code": "3083597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 134.5762,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-BIOGLUE FAN        BGST-12",
      "code_information": [
        {
          "code": "3083615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 82.7313,
          "maximum": 593.3587,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 161.5698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE ALL    UMx67x's",
      "code_information": [
        {
          "code": "3083622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1067,
          "minimum": 207.4253,
          "maximum": 774.3219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 712.3761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 35CM     3908",
      "code_information": [
        {
          "code": "3083637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 311.1221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CURVED DISP I&A 8065751512",
      "code_information": [
        {
          "code": "3083715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE POLYMER I/A",
      "code_information": [
        {
          "code": "3083720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 222,
          "minimum": 75.894,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-TURBOSONICS     8065750853",
      "code_information": [
        {
          "code": "3083760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 50.6051,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 498.7301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EMBLEM TUNNELING 4711",
      "code_information": [
        {
          "code": "3084601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5623.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-LUKI MUCOUS SPEC  8646-04",
      "code_information": [
        {
          "code": "3084800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 6",
      "code_information": [
        {
          "code": "3084821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 321.353,
          "maximum": 726.2666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 627.5854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA70",
      "code_information": [
        {
          "code": "3084824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.9431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA80",
      "code_information": [
        {
          "code": "3084827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1345,
          "minimum": 100.098,
          "maximum": 976.0665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 897.9812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/METER ALL P4PxxSD",
      "code_information": [
        {
          "code": "3084870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 130.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.1759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CHG PREP        DYND70663",
      "code_information": [
        {
          "code": "3084874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 65.313,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BETADINE PREP   DYND70672",
      "code_information": [
        {
          "code": "3084876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 3099.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1    4609764",
      "code_information": [
        {
          "code": "3084884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 111.7578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.8172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAPS-FINGER DISP PACK 9900s",
      "code_information": [
        {
          "code": "3084885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 190,
          "minimum": 64.9543,
          "maximum": 12260.3367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.8524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-LAP CB EXPLOR    G26908",
      "code_information": [
        {
          "code": "3084925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3560,
          "minimum": 443.2117,
          "maximum": 2583.492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2376.8126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SOLU IRRISEPT .5% CHG",
      "code_information": [
        {
          "code": "3084928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 797,
          "minimum": 272.4663,
          "maximum": 3137.5162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 532.1123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP 26-23-0757",
      "code_information": [
        {
          "code": "3084992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 7593.5455,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.2756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFF74",
      "code_information": [
        {
          "code": "3085110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 503.8266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-100LP",
      "code_information": [
        {
          "code": "3085111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 906,
          "minimum": 174.6154,
          "maximum": 657.4842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 604.8855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED     CTF73",
      "code_information": [
        {
          "code": "3085112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 523.2901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-100L",
      "code_information": [
        {
          "code": "3085113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 941,
          "minimum": 141.2494,
          "maximum": 682.8837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 628.253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREATED      CTF03",
      "code_information": [
        {
          "code": "3085117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-8MM KII OPTICAL   COQ19",
      "code_information": [
        {
          "code": "3085120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR47",
      "code_information": [
        {
          "code": "3085135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR85",
      "code_information": [
        {
          "code": "3085137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 315.3087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM KII OPTICAL  COR37",
      "code_information": [
        {
          "code": "3085140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 567,
          "minimum": 193.8374,
          "maximum": 411.4719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 378.5541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM LONG         C0R39",
      "code_information": [
        {
          "code": "3085142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 567,
          "minimum": 149.5909,
          "maximum": 411.4719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 378.5541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM KII FIOS      CFFxx",
      "code_information": [
        {
          "code": "3085145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM LONG BLADED CFB71",
      "code_information": [
        {
          "code": "3085160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 490.4802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-THORACOPOR 11.5  179303",
      "code_information": [
        {
          "code": "3085163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 882,
          "minimum": 178.5081,
          "maximum": 640.0674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 588.862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM THREADED     CTF33",
      "code_information": [
        {
          "code": "3085165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 1116.0927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-SPLIT           82-4095",
      "code_information": [
        {
          "code": "3085170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2007,
          "minimum": 268.0402,
          "maximum": 1456.4799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1339.9615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL BLADELESS     B8LT",
      "code_information": [
        {
          "code": "3085202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 482,
          "minimum": 164.7789,
          "maximum": 760.1887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.8044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP LONG VS101505",
      "code_information": [
        {
          "code": "3085203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1367,
          "minimum": 467.3293,
          "maximum": 992.0319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 912.6693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 5MM           B5LT",
      "code_information": [
        {
          "code": "3085207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1543,
          "minimum": 390.3822,
          "maximum": 1119.7551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1030.1747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BIO PREP BONE PREP",
      "code_information": [
        {
          "code": "3085533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1349,
          "minimum": 100.6541,
          "maximum": 978.9693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 900.6518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 8.0FR MEGA IAB",
      "code_information": [
        {
          "code": "3085537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1496,
          "minimum": 511.4298,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 998.7954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ARMSTRONG TEFLON DRAIN",
      "code_information": [
        {
          "code": "3085540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.8846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-TIBIAL 111651",
      "code_information": [
        {
          "code": "3085541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 757.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 284.4163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PROCEDURE TRACKING 107130",
      "code_information": [
        {
          "code": "3085542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 225.2205,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 909.3311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE 111320",
      "code_information": [
        {
          "code": "3085543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 405,
          "minimum": 138.4553,
          "maximum": 454.3337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 270.3958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX IMPACTION",
      "code_information": [
        {
          "code": "3085544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 817,
          "minimum": 279.3036,
          "maximum": 592.8969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 545.4651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144140",
      "code_information": [
        {
          "code": "3085545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 685.7865,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 630.9236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON ULTRASIL",
      "code_information": [
        {
          "code": "3085560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-ENDO EXCEL 15MM   B15LT",
      "code_information": [
        {
          "code": "3085620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1548,
          "minimum": 529.2068,
          "maximum": 1123.3836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1033.5129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR ARMSTRONG    10-56121",
      "code_information": [
        {
          "code": "3085635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 155.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.8758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR PAPARELLA 1.14MM",
      "code_information": [
        {
          "code": "3085636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 881.4185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.8758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACHEAL EMG  8229307",
      "code_information": [
        {
          "code": "3085638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1585,
          "minimum": 88.976,
          "maximum": 1150.2345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1058.2157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH ALL SZS 822970x",
      "code_information": [
        {
          "code": "3085644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2759,
          "minimum": 207.9814,
          "maximum": 2002.2063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1842.0298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 20FR   0100-20",
      "code_information": [
        {
          "code": "3085648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 491.0363,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.6989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-KAMVAC            5300-00",
      "code_information": [
        {
          "code": "3085723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 301.8667,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 589.5297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MOSS GASTROSTOMY  5-17719",
      "code_information": [
        {
          "code": "3085779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 375.9236,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1232.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T MODIFIED        24-0072",
      "code_information": [
        {
          "code": "3085882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 230.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.3108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COLLECTION DISP BKT-506",
      "code_information": [
        {
          "code": "3086006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 83.415,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.6285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OXYFLEX        SA008000",
      "code_information": [
        {
          "code": "3086095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX INFLOW  AQL-110",
      "code_information": [
        {
          "code": "3086102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      80-9102",
      "code_information": [
        {
          "code": "3086103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 715,
          "minimum": 99.5419,
          "maximum": 518.8755,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 477.3655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      5120-10",
      "code_information": [
        {
          "code": "3086105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 535.5243,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.8905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AIRSEAL ASM-EVAC",
      "code_information": [
        {
          "code": "3086106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 963,
          "minimum": 301.4062,
          "maximum": 698.8491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 642.9412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATOR STR  18-95522",
      "code_information": [
        {
          "code": "3086107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 542,
          "minimum": 43.3758,
          "maximum": 393.3294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LASER VACUUM    VT10424",
      "code_information": [
        {
          "code": "3086109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 93.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.0762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LIPOSUCTION   DYND50112",
      "code_information": [
        {
          "code": "3086110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 425.4165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MAIN PUMP       AR-6410",
      "code_information": [
        {
          "code": "3086111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 99.5419,
          "maximum": 555.1605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 510.7477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/4\\\"X1/16\\\"X8'      3108",
      "code_information": [
        {
          "code": "3086139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 132,
          "minimum": 45.1262,
          "maximum": 279.1622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OUTFLOW         AR-6430",
      "code_information": [
        {
          "code": "3086141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO      284508",
      "code_information": [
        {
          "code": "3086142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 450,
          "minimum": 153.8392,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 300.4398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO IRRIG OUT",
      "code_information": [
        {
          "code": "3086144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 109.5517,
          "maximum": 441.9513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 406.5952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-ASPIRATION AT-10003-6",
      "code_information": [
        {
          "code": "3086181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 349.7869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 131.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TISSEEL         0600065",
      "code_information": [
        {
          "code": "3086182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 629,
          "minimum": 112.8883,
          "maximum": 456.4653,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 419.9481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TRANSDUCER 48 61000",
      "code_information": [
        {
          "code": "3086185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 165.7178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.5317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARTHREX-TIB CANN      AR-1802D",
      "code_information": [
        {
          "code": "3086190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 456.5581,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-& TIP-SMALL   9009-18",
      "code_information": [
        {
          "code": "3086203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 821,
          "minimum": 280.6711,
          "maximum": 595.7997,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 548.1357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER & TIP-LARGE   9009-16",
      "code_information": [
        {
          "code": "3086205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 724,
          "minimum": 247.5102,
          "maximum": 1804.5445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 483.3743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-STIMULATOR LEAD   402",
      "code_information": [
        {
          "code": "3086210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3245,
          "minimum": 207.4253,
          "maximum": 2354.8965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2166.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE SUPPORT 79-82160",
      "code_information": [
        {
          "code": "3086407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 504.9388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 70x-xxxx ALL SIZES",
      "code_information": [
        {
          "code": "3086409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 341.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.0459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH 2-0   170057",
      "code_information": [
        {
          "code": "3086965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 813,
          "minimum": 277.9361,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 542.7946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VAC-SUPER TURBO     ASC4250-01",
      "code_information": [
        {
          "code": "3087110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 58.9466,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP CVD ALL 21500s",
      "code_information": [
        {
          "code": "3087119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CURVED 7MM     21853",
      "code_information": [
        {
          "code": "3087130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 72.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.7644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 8MM CVD   20317",
      "code_information": [
        {
          "code": "3087132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 2133.1996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VOICE-PROLARYN        8044M0K5",
      "code_information": [
        {
          "code": "3087140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3836,
          "minimum": 1311.3936,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2561.0824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVULATOME-LEMAITRE   1009-00",
      "code_information": [
        {
          "code": "3087919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 13534,
          "minimum": 870.8526,
          "maximum": 9821.6238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9035.8939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8916-14",
      "code_information": [
        {
          "code": "3087939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 812,
          "minimum": 277.5943,
          "maximum": 589.2684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 542.1269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 UNDYED    VLOCM1904",
      "code_information": [
        {
          "code": "3088955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 7.7854,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J761D",
      "code_information": [
        {
          "code": "3088965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 309.7477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VIOLET    VLOCM0804",
      "code_information": [
        {
          "code": "3088967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 557,
          "minimum": 58.9466,
          "maximum": 404.2149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 371.8777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0    MCP496G",
      "code_information": [
        {
          "code": "3088972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 7.7854,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J441",
      "code_information": [
        {
          "code": "3088976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 34.4782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8.0117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS2     1666G",
      "code_information": [
        {
          "code": "3088979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J218H",
      "code_information": [
        {
          "code": "3088985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 8.7084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8.0117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y495G",
      "code_information": [
        {
          "code": "3088991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 444.3239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       D5526",
      "code_information": [
        {
          "code": "3088992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 799,
          "minimum": 35.5904,
          "maximum": 579.8343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 533.4476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 6-0           Z432H",
      "code_information": [
        {
          "code": "3088993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 7.7854,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0  ALL  833-000s",
      "code_information": [
        {
          "code": "3088998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 533,
          "minimum": 7.7854,
          "maximum": 386.7981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 355.8543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J727D",
      "code_information": [
        {
          "code": "3089002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 7.7854,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.8377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J905T",
      "code_information": [
        {
          "code": "3089005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 97.3175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J739D",
      "code_information": [
        {
          "code": "3089007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 7.7854,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.8377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J906G",
      "code_information": [
        {
          "code": "3089013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 107.4036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.8113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J740D",
      "code_information": [
        {
          "code": "3089014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 7.7854,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.8377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J775D",
      "code_information": [
        {
          "code": "3089024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.4936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J789D",
      "code_information": [
        {
          "code": "3089025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 45.6002,
          "maximum": 156.7512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z881G",
      "code_information": [
        {
          "code": "3089026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 124.5664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8806H",
      "code_information": [
        {
          "code": "3089027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 53.3856,
          "maximum": 162.5568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z990G",
      "code_information": [
        {
          "code": "3089030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 7.7854,
          "maximum": 69.6672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J834G",
      "code_information": [
        {
          "code": "3089039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J833G",
      "code_information": [
        {
          "code": "3089042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8824G",
      "code_information": [
        {
          "code": "3089048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 7.7854,
          "maximum": 42.8163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y493G",
      "code_information": [
        {
          "code": "3089059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y490G",
      "code_information": [
        {
          "code": "3089060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 7.7854,
          "maximum": 72.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.7644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8521H",
      "code_information": [
        {
          "code": "3089064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8581H",
      "code_information": [
        {
          "code": "3089065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 75.4728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 69.435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8557H",
      "code_information": [
        {
          "code": "3089066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8833H",
      "code_information": [
        {
          "code": "3089069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8623H",
      "code_information": [
        {
          "code": "3089072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 55.0539,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8522H",
      "code_information": [
        {
          "code": "3089073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8534H",
      "code_information": [
        {
          "code": "3089074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J904T",
      "code_information": [
        {
          "code": "3089079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 7.7854,
          "maximum": 84.9069,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      PX82H",
      "code_information": [
        {
          "code": "3089097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8523H",
      "code_information": [
        {
          "code": "3089100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 112.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8706H",
      "code_information": [
        {
          "code": "3089103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.5317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8805H",
      "code_information": [
        {
          "code": "3089105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 161.8311,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.8846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8709H",
      "code_information": [
        {
          "code": "3089106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 266,
          "minimum": 90.9361,
          "maximum": 193.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 177.5933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8720H",
      "code_information": [
        {
          "code": "3089110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 50.6051,
          "maximum": 142.2372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.8582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8556H",
      "code_information": [
        {
          "code": "3089113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 66.0387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8710H",
      "code_information": [
        {
          "code": "3089114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 133.464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.4203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8304H",
      "code_information": [
        {
          "code": "3089117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 240,
          "minimum": 82.0476,
          "maximum": 174.168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.2346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8703H",
      "code_information": [
        {
          "code": "3089121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 251,
          "minimum": 85.8081,
          "maximum": 182.1507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 167.5786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J213H",
      "code_information": [
        {
          "code": "3089123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 7.7854,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO       AR-4068-xxx",
      "code_information": [
        {
          "code": "3089131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 33.9221,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         G124H",
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        {
          "code": "3089132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         U256H",
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        {
          "code": "3089133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 2-0       G123H",
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        {
          "code": "3089145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 19.4863,
          "maximum": 148.4787,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       1792G",
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        {
          "code": "3089146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 193.7619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
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        {
          "code": "3089147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 179.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 0       L104G",
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        {
          "code": "3089150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 61.7271,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       G172H",
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        {
          "code": "3089154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 33.9221,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U203",
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        {
          "code": "3089156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1637G",
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        {
          "code": "3089157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 69.6672,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0     1916G",
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        {
          "code": "3089161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     1824H",
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        {
          "code": "3089172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A304H",
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        {
          "code": "3089177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 5-0          K890H",
      "code_information": [
        {
          "code": "3089195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 7.7854,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 56.0821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           709H",
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        {
          "code": "3089202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 118,
          "minimum": 40.3401,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0  X524H",
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        {
          "code": "3089204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 7.7854,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5        B449T",
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        {
          "code": "3089212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 4-0      X204H",
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        {
          "code": "3089217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 3-0      X936H",
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          "code": "3089226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 30.0841,
          "maximum": 93.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5-0      X727H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        690G",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       1666H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1663H",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-PDS 0             Z340H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 3.4186,
          "maximum": 7.7854,
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            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 0         L880G",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      SXP82",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 207.512,
          "maximum": 440.4999,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND2-0       SXP86",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 483.3162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X927H",
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        {
          "code": "3089281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z879G",
      "code_information": [
        {
          "code": "3089283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0 Z494G",
      "code_information": [
        {
          "code": "3089284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.0821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y497G",
      "code_information": [
        {
          "code": "3089286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 66.0387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0        687G",
      "code_information": [
        {
          "code": "3089287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.7585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X513H",
      "code_information": [
        {
          "code": "3089288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.0616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2 MX69G",
      "code_information": [
        {
          "code": "3089290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 73.8428,
          "maximum": 215.2107,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS O EZ10G",
      "code_information": [
        {
          "code": "3089291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 280.8459,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 258.3782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          EJ10G",
      "code_information": [
        {
          "code": "3089292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 345.8942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 258.3782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       M8720",
      "code_information": [
        {
          "code": "3089293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 622,
          "minimum": 212.6399,
          "maximum": 451.3854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 415.2746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       M8303",
      "code_information": [
        {
          "code": "3089294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 778,
          "minimum": 7.7854,
          "maximum": 564.5946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 519.427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       U202H",
      "code_information": [
        {
          "code": "3089307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U213H",
      "code_information": [
        {
          "code": "3089308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 49.4929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8843H",
      "code_information": [
        {
          "code": "3089314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 100.6541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.4203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J555G",
      "code_information": [
        {
          "code": "3089316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            C027D",
      "code_information": [
        {
          "code": "3089318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.1642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX45D",
      "code_information": [
        {
          "code": "3089320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 207,
          "minimum": 70.766,
          "maximum": 150.2199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.2023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 8-0         2815G",
      "code_information": [
        {
          "code": "3089323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 35.0343,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.5317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X523H",
      "code_information": [
        {
          "code": "3089324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.0616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X977H",
      "code_information": [
        {
          "code": "3089325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 5-0     1915G",
      "code_information": [
        {
          "code": "3089326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 167.9422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0           Z774D",
      "code_information": [
        {
          "code": "3089328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 7.7854,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.6285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 10-0      9003G",
      "code_information": [
        {
          "code": "3089335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 7.7854,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.9198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        793G",
      "code_information": [
        {
          "code": "3089348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 192,
          "minimum": 37.8148,
          "maximum": 139.3344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 128.1876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 699G",
      "code_information": [
        {
          "code": "3089354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON/MONO    ETH562H",
      "code_information": [
        {
          "code": "3089357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 CT1  J-945-H",
      "code_information": [
        {
          "code": "3089362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 33.366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.6764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0        585H",
      "code_information": [
        {
          "code": "3089363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C0125",
      "code_information": [
        {
          "code": "3089364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 179.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMD2B413",
      "code_information": [
        {
          "code": "3089371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 322,
          "minimum": 110.0805,
          "maximum": 233.6754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.9814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPD2B408",
      "code_information": [
        {
          "code": "3089372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 34.4782,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 229.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       U204H",
      "code_information": [
        {
          "code": "3089379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J428H",
      "code_information": [
        {
          "code": "3089381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 46,
          "minimum": 15.7258,
          "maximum": 38.3709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 30.7116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6/0 P-1    J489G",
      "code_information": [
        {
          "code": "3089382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 7-0        J488G",
      "code_information": [
        {
          "code": "3089384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPP1A400",
      "code_information": [
        {
          "code": "3089386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 370,
          "minimum": 99.5419,
          "maximum": 268.509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 247.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2.0 ALL PX83Hs",
      "code_information": [
        {
          "code": "3089390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1654G",
      "code_information": [
        {
          "code": "3089394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 7.7854,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NUROLON 4-0       C584D",
      "code_information": [
        {
          "code": "3089396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 236,
          "minimum": 80.6801,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 157.564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPD2B413",
      "code_information": [
        {
          "code": "3089403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 391,
          "minimum": 48.9368,
          "maximum": 283.7487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 261.0488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z493G",
      "code_information": [
        {
          "code": "3089407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN 4-0 1644G",
      "code_information": [
        {
          "code": "3089408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE RS23",
      "code_information": [
        {
          "code": "3089410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 378.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.6989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC PBT xxMM",
      "code_information": [
        {
          "code": "3089416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 1362.445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 454.6656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1B406",
      "code_information": [
        {
          "code": "3089420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 380,
          "minimum": 129.9086,
          "maximum": 275.766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 253.7047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MONOPTY 16GX20CM",
      "code_information": [
        {
          "code": "3089701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 1121.6537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 248.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE EICA8875-01",
      "code_information": [
        {
          "code": "3090040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2017,
          "minimum": 689.5414,
          "maximum": 1463.7369,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1346.6379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-TURBINATE RED EICA4845-01",
      "code_information": [
        {
          "code": "3090049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2053,
          "minimum": 701.8486,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1370.6731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,TOPAZ MICRO ACH4041-0",
      "code_information": [
        {
          "code": "3090061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1792.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .045      WS-1106ST",
      "code_information": [
        {
          "code": "3090191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER #2          AR-7200",
      "code_information": [
        {
          "code": "3091195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.0195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER 2-0         AR-7220",
      "code_information": [
        {
          "code": "3091196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.0195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5         310.243",
      "code_information": [
        {
          "code": "3091211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 291.2689,
          "maximum": 618.2964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 568.8327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6MM AGK16150",
      "code_information": [
        {
          "code": "3091237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 311.1221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-2.5MM DRILL XFO082501",
      "code_information": [
        {
          "code": "3091238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1046.1981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE          1806-0080S",
      "code_information": [
        {
          "code": "3091250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1197,
          "minimum": 207.4253,
          "maximum": 868.6629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 799.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3091317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .054          WS-1406ST",
      "code_information": [
        {
          "code": "3091319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K              0152-0218S",
      "code_information": [
        {
          "code": "3091346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 881,
          "minimum": 99.5419,
          "maximum": 639.3417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 588.1944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 040-365",
      "code_information": [
        {
          "code": "3091419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1510,
          "minimum": 198.5277,
          "maximum": 1095.807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1008.1424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 046-072",
      "code_information": [
        {
          "code": "3091422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 357,
          "minimum": 122.0458,
          "maximum": 259.0749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 238.3489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY    047-032",
      "code_information": [
        {
          "code": "3091425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 295,
          "minimum": 100.8501,
          "maximum": 342.5576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 196.955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE TIP      03.211.410",
      "code_information": [
        {
          "code": "3091436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 616,
          "minimum": 157.3763,
          "maximum": 447.0312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 411.2687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 5.0 310.63",
      "code_information": [
        {
          "code": "3091500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3340,
          "minimum": 55.61,
          "maximum": 2423.838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2229.931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 21665",
      "code_information": [
        {
          "code": "3091501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.7644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-PROGEL PGPS002",
      "code_information": [
        {
          "code": "3091508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 494.929,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION SEID",
      "code_information": [
        {
          "code": "3091510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 890,
          "minimum": 304.2597,
          "maximum": 645.873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 594.2032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND M 2.5MM 03.000.007S",
      "code_information": [
        {
          "code": "3091511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 105.659,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 528.774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/2X3/32 /10 3610",
      "code_information": [
        {
          "code": "3091513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 190,
          "minimum": 64.9543,
          "maximum": 645.076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.8524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLUE-GUN CMS REVOLUTION",
      "code_information": [
        {
          "code": "3091516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1029,
          "minimum": 351.7789,
          "maximum": 1269.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 687.0057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT 5MM EB210",
      "code_information": [
        {
          "code": "3091517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 1656.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1523.5636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT FINE EB230",
      "code_information": [
        {
          "code": "3091518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2953,
          "minimum": 313.6404,
          "maximum": 2142.9921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1971.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE CANNU FLEX .042X12",
      "code_information": [
        {
          "code": "3091560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 121.2298,
          "maximum": 409.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 376.5512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TEMPORARY CARDIA  024-100",
      "code_information": [
        {
          "code": "3091561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 158.2026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 145.5464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8MM FIBULA ROD 80-0642",
      "code_information": [
        {
          "code": "3091572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.9431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-FACIAL DENTAL 714-6IN-GEL",
      "code_information": [
        {
          "code": "3093187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 249,
          "minimum": 85.1244,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 166.2434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ACCESSORY       3550-02",
      "code_information": [
        {
          "code": "3093195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 207.4253,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 627.5854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOBUTTON-CL ULTRA PAC 1.2",
      "code_information": [
        {
          "code": "3094000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2461,
          "minimum": 841.3294,
          "maximum": 1785.9477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1643.0719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACCESSORY-TIP COVER     400180",
      "code_information": [
        {
          "code": "3100010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SNAPFIT 15 DEG    400152",
      "code_information": [
        {
          "code": "3102750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCL0316",
      "code_information": [
        {
          "code": "3115410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 184.9489,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCM1545",
      "code_information": [
        {
          "code": "3115420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 184.9489,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 361.1954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA ARM        420279",
      "code_information": [
        {
          "code": "3115515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA HEAD       420273",
      "code_information": [
        {
          "code": "3115525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM    420015",
      "code_information": [
        {
          "code": "3115580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM XI 470015",
      "code_information": [
        {
          "code": "3115585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 652,
          "minimum": 156.8202,
          "maximum": 473.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 435.3039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM LONG XI   470358",
      "code_information": [
        {
          "code": "3155025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 272.8632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.0341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM XI        470357",
      "code_information": [
        {
          "code": "3155030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 272.8632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.0341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 5MM        400161",
      "code_information": [
        {
          "code": "3170005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 8.5-13MM   420206",
      "code_information": [
        {
          "code": "3170007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 124.5664,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA            400077",
      "code_information": [
        {
          "code": "3170010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA ENDOWRIST XI",
      "code_information": [
        {
          "code": "3170020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-8MM XI 570361",
      "code_information": [
        {
          "code": "3170050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 96.4059,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 188.2756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL s.I.e.    410322",
      "code_information": [
        {
          "code": "3170060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.6403,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2241.2809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL XI        480322",
      "code_information": [
        {
          "code": "3170070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 170.1666,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2241.2809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUB. & FILTER 20400162S/10",
      "code_information": [
        {
          "code": "3171250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 306,
          "minimum": 104.6106,
          "maximum": 222.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 204.2991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-ENDOWRIST STAPLER 45",
      "code_information": [
        {
          "code": "3171320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 6652.0682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909506",
      "code_information": [
        {
          "code": "3171350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11962,
          "minimum": 976.5116,
          "maximum": 8680.8234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7986.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 12M OMS-T12BT",
      "code_information": [
        {
          "code": "3175750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1756,
          "minimum": 600.3147,
          "maximum": 1274.3292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1172.3829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-SINGLE SITE 8.5    428065",
      "code_information": [
        {
          "code": "3185345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1488,
          "minimum": 508.6949,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 993.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEXIBLE         3100A",
      "code_information": [
        {
          "code": "3240013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1449,
          "minimum": 201.3082,
          "maximum": 1051.5393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 967.4162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GENERATOR INFANT LP FLOW",
      "code_information": [
        {
          "code": "3240072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 596,
          "minimum": 203.7515,
          "maximum": 432.5172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 397.9158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INFANT O2 DELIVERY   RT329",
      "code_information": [
        {
          "code": "3240073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 476,
          "minimum": 62.2832,
          "maximum": 345.4332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 317.7985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RESUS S/USE       900RD010",
      "code_information": [
        {
          "code": "3240075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 433.758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG HYDROGEL",
      "code_information": [
        {
          "code": "3240083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODES-EEG LOW IMPEDENCE",
      "code_information": [
        {
          "code": "3240085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 72.8491,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.6989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTERFACE-TRACHEOSTOMY HI FLOW",
      "code_information": [
        {
          "code": "3240105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 273.0451,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 218.3196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BELLOWS & WATER TRAP 3100A",
      "code_information": [
        {
          "code": "3240167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 177.3959,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 598.209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CONNECTING TUBING.   3100",
      "code_information": [
        {
          "code": "3240170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 319,
          "minimum": 109.0549,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.9784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 6 FR    196",
      "code_information": [
        {
          "code": "3249995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 124.8494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 8 FR    198",
      "code_information": [
        {
          "code": "3249997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 124.8494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE MAC 5FR    1925",
      "code_information": [
        {
          "code": "3249998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 65.2962,
          "maximum": 138.6087,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 127.52,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE 14FR 12\\\" 220135",
      "code_information": [
        {
          "code": "3250000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 81.4526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT UNCUFFED",
      "code_information": [
        {
          "code": "3281990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 47.8246,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 598.209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3282370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XS      006950",
      "code_information": [
        {
          "code": "3283013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 196.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.8465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP THERAPY  \\\"ACAPELLA\\\"",
      "code_information": [
        {
          "code": "3283015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 111.22,
          "maximum": 256.8978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 236.346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION  LG     006965",
      "code_information": [
        {
          "code": "3283017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 133.5288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XLG     006970",
      "code_information": [
        {
          "code": "3283018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 133.5288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUVETTE-CO2 DISP ADULT MP01062",
      "code_information": [
        {
          "code": "3284354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 198,
          "minimum": 53.9417,
          "maximum": 143.6886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 132.1935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER 5MM",
      "code_information": [
        {
          "code": "3290045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 176.8398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL MED HIGH FLOW",
      "code_information": [
        {
          "code": "3290046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 230.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.3108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL SM HIGH FLOW",
      "code_information": [
        {
          "code": "3290047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL LG HIGH FLOW",
      "code_information": [
        {
          "code": "3290048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP           23-0757",
      "code_information": [
        {
          "code": "3290060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 91.2004,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 202.9638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT L599-130",
      "code_information": [
        {
          "code": "3290061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 205.757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.4936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT W/MR290 SINGLE",
      "code_information": [
        {
          "code": "3290062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 370,
          "minimum": 126.49,
          "maximum": 268.509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 247.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BREATHING NEONATAL",
      "code_information": [
        {
          "code": "3290074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.1261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-INFANT DUAL FLOW RT26",
      "code_information": [
        {
          "code": "3290077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 82.3028,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 295.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOWMETER-PEAK          002068",
      "code_information": [
        {
          "code": "3290080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 107.4036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.8113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-CPAP NASAL NSC-001",
      "code_information": [
        {
          "code": "3290082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.1231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOW-CONT CYSTO GREENLYT",
      "code_information": [
        {
          "code": "3290084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 102.3224,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP MED",
      "code_information": [
        {
          "code": "3290127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 133.5288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.8465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP SMALL",
      "code_information": [
        {
          "code": "3290128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 133.5288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.8465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOSE-AIR MODEL 205 DISP",
      "code_information": [
        {
          "code": "3290145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 174.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED SM NIV",
      "code_information": [
        {
          "code": "3290170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.9726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED MED NIV",
      "code_information": [
        {
          "code": "3290171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.9726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED LG NIV",
      "code_information": [
        {
          "code": "3290172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 56.7222,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.9726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 42MM    RD804-10",
      "code_information": [
        {
          "code": "3290178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.0997,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP AIRLIFE W/FILTER",
      "code_information": [
        {
          "code": "3290184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 171.8349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL XS INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 309,
          "minimum": 105.6362,
          "maximum": 224.2413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 206.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL LG INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL MED INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 206.8245,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 190.2785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 308,
          "minimum": 58.3905,
          "maximum": 223.5156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 205.6344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 60MM    RD806-10",
      "code_information": [
        {
          "code": "3290194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 76.1985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.1026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK,OXY ADULT OM-1125-8",
      "code_information": [
        {
          "code": "3290214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 149.0348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.4115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED SMALL NIV",
      "code_information": [
        {
          "code": "3290215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.9286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.6285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED LARGE NIV",
      "code_information": [
        {
          "code": "3290217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.9286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 78.9708,
          "maximum": 167.6367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 154.2258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED LG NIV",
      "code_information": [
        {
          "code": "3290219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 391.4944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP ALOHA ALO100",
      "code_information": [
        {
          "code": "3290220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 704,
          "minimum": 66.1759,
          "maximum": 510.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 470.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-MISTY FINITY  002534",
      "code_information": [
        {
          "code": "3290245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 119,
          "minimum": 40.6819,
          "maximum": 422.636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 79.4496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOPPER-DECANNULATION SZ4",
      "code_information": [
        {
          "code": "3290354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 760,
          "minimum": 194.635,
          "maximum": 551.532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 507.4094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DIRECTIONAL BALLARD  22059",
      "code_information": [
        {
          "code": "3290385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 388.7139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 5MM PROX",
      "code_information": [
        {
          "code": "3290400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 699,
          "minimum": 238.9635,
          "maximum": 507.2643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 466.6832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY SLT UNCUFF 5MM",
      "code_information": [
        {
          "code": "3290401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 679,
          "minimum": 232.1262,
          "maximum": 492.7503,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 453.3303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEST-SPU ALL SZS  WRAP-SLOTTED",
      "code_information": [
        {
          "code": "3290504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 819,
          "minimum": 279.9873,
          "maximum": 594.3483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 546.8004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING WHITE    PMV005",
      "code_information": [
        {
          "code": "3290506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 876,
          "minimum": 299.4736,
          "maximum": 635.7132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 584.8561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING PURPLE  PMV2001",
      "code_information": [
        {
          "code": "3290508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 875,
          "minimum": 33.366,
          "maximum": 634.9875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 584.1885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP LPEEP",
      "code_information": [
        {
          "code": "3290509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP ADJ          2K8082",
      "code_information": [
        {
          "code": "3290515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 265.2597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-THERAPRESSURE     262895",
      "code_information": [
        {
          "code": "3300010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 51,
          "minimum": 17.4351,
          "maximum": 582.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 34.0498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOFT GOODS FOR CPM UNIT",
      "code_information": [
        {
          "code": "3302945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 325.8746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 219.6549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA VARICEX S",
      "code_information": [
        {
          "code": "3310024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.4145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-ENDURA KIT         775410",
      "code_information": [
        {
          "code": "3310985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.8142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BGE   A840235",
      "code_information": [
        {
          "code": "3310986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 91.4382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.1231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BLACK  554617",
      "code_information": [
        {
          "code": "3310987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 53.6728,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.8201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX RED   A840241",
      "code_information": [
        {
          "code": "3310989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 89.9868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.7879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 6CMX5CM",
      "code_information": [
        {
          "code": "3310991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 8CMX5CM",
      "code_information": [
        {
          "code": "3310992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 10CMX5M",
      "code_information": [
        {
          "code": "3310993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.1173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDL K 12CMX5M",
      "code_information": [
        {
          "code": "3311000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 100.098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL 15CMX.4CMX2.5M",
      "code_information": [
        {
          "code": "3311010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 161.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.1759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ12 12CM",
      "code_information": [
        {
          "code": "3311075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 290,
          "minimum": 84.5272,
          "maximum": 210.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 193.6168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ7 7CM",
      "code_information": [
        {
          "code": "3311076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL SOFT",
      "code_information": [
        {
          "code": "3311078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 126.2347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING C",
      "code_information": [
        {
          "code": "3311085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 164.7339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 151.5552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AID-\\\"CLEAN EASY\\\" GRIP REACH",
      "code_information": [
        {
          "code": "3311086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 203.196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.9403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING D",
      "code_information": [
        {
          "code": "3311094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 391.4944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 145.5464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3311107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 29.4733,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-LG HDL      C6298-01-25",
      "code_information": [
        {
          "code": "3311117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 53,
          "minimum": 18.1188,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 35.3851,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3311123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.1612,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 6CMX5M",
      "code_information": [
        {
          "code": "3311138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 74.5174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 8CMX5M RL",
      "code_information": [
        {
          "code": "3311139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 44.488,
          "maximum": 97.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-IONTOPHOR IOGEL 2971",
      "code_information": [
        {
          "code": "3311144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 58.3905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.4115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYBRESIS PATCH",
      "code_information": [
        {
          "code": "3311150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 33.366,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALU 1.5X3.5 PK 2393",
      "code_information": [
        {
          "code": "3311153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 86.1955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ALUM LTX FREE ALL",
      "code_information": [
        {
          "code": "3311156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 103.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXERCISER-POWER GRIP HAND",
      "code_information": [
        {
          "code": "3311157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 63.5869,
          "maximum": 402.0603,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 124.1818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-COMFY HAND/THUMB",
      "code_information": [
        {
          "code": "3311158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 723,
          "minimum": 28.3611,
          "maximum": 524.6811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.7066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3311161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 37.2587,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUTRODE RND 1.25\\\"",
      "code_information": [
        {
          "code": "3311163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT OVAL PK 2\\\"X4\\\"",
      "code_information": [
        {
          "code": "3311164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.4057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-WEIGHTED EZ GRIP 920675",
      "code_information": [
        {
          "code": "3311165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 91.7565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELECTRODE ADULT       9050",
      "code_information": [
        {
          "code": "3311167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 141.8055,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.1613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3311174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 36.7026,
          "maximum": 185.0535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT SQ PK  1.5X3.5",
      "code_information": [
        {
          "code": "3311178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 293.0647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.0645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT M&LGE",
      "code_information": [
        {
          "code": "3311191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 48.3807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARD-FOOD INVISIBLE      1115",
      "code_information": [
        {
          "code": "3311192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 87.3077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-TRACTION EXER ALL C5032s",
      "code_information": [
        {
          "code": "3311193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 35.5904,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.8201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT S&XS",
      "code_information": [
        {
          "code": "3311194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 280.2744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LAVAGE    0210112000",
      "code_information": [
        {
          "code": "3311197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 504,
          "minimum": 172.2999,
          "maximum": 365.7528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 336.4926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPM SOFTGOOD FOR HOME UNIT",
      "code_information": [
        {
          "code": "3311235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 238.7553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 219.6549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3311250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 319,
          "minimum": 104.5468,
          "maximum": 231.4983,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.9784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HIP/KNEE W/26 REACHER",
      "code_information": [
        {
          "code": "3311251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH UPPER EXTREMITY",
      "code_information": [
        {
          "code": "3311255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 28.9172,
          "maximum": 134.9802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 124.1818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-ELASTO-GEL CAST/SPL  A8273",
      "code_information": [
        {
          "code": "3311340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 65.0637,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 34.7175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3311347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3311357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 87.8638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-D WRIST BRACE ALL SIZES",
      "code_information": [
        {
          "code": "3311363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADDING-FOAM \\\"KOMPREX\\\" SHEET",
      "code_information": [
        {
          "code": "3311369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.8377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPOON-WEIGHTED EZ GRIP 920688",
      "code_information": [
        {
          "code": "3311406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-LONG-32\\\"       A665009",
      "code_information": [
        {
          "code": "3311472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 28.9172,
          "maximum": 84.9069,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-ALUMINUM 32\\\"      4107",
      "code_information": [
        {
          "code": "3311475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 37.7364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 34.7175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-STANDARD 26\\\"    A80-42",
      "code_information": [
        {
          "code": "3311479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-SAMMONS PRESTON   4109",
      "code_information": [
        {
          "code": "3311480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINTING-EZEFORM 1/8”X18”X24”",
      "code_information": [
        {
          "code": "3311600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 475,
          "minimum": 92.3126,
          "maximum": 344.7075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 317.1309,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELBOW NEOPRENE XL",
      "code_information": [
        {
          "code": "3311602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 166,
          "minimum": 56.7496,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.8289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-JOINT JACK MED   A52542",
      "code_information": [
        {
          "code": "3311613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 203.9217,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 187.608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 6\\\"-7\\\"",
      "code_information": [
        {
          "code": "3311625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 229.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 3-14",
      "code_information": [
        {
          "code": "3311701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT S/M A812731",
      "code_information": [
        {
          "code": "3311702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 248.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND COMFY LG ADULT",
      "code_information": [
        {
          "code": "3311703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 444,
          "minimum": 151.788,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 296.4339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT/LARGE DYNAPRO",
      "code_information": [
        {
          "code": "3311704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 498.7301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-STABILIZER WALKER ROLYAN",
      "code_information": [
        {
          "code": "3311708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 463,
          "minimum": 158.2834,
          "maximum": 335.9991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 309.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WALKER HIGH OVATION LRG",
      "code_information": [
        {
          "code": "3311709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 549,
          "minimum": 23.3562,
          "maximum": 398.4093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 366.5366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-LMB FINGER HUGGER",
      "code_information": [
        {
          "code": "3312530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 83.7569,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 163.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EZEFORM-ANTI MICROBIAL 564393",
      "code_information": [
        {
          "code": "3315521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 572,
          "minimum": 121.7859,
          "maximum": 415.1004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.8924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3397811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 349,
          "minimum": 47.2685,
          "maximum": 253.2693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.0078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PALM SHIELD RIGHT",
      "code_information": [
        {
          "code": "3397815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.1261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND RIGHT/MED A31228",
      "code_information": [
        {
          "code": "3397817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 226.4184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.3049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT MED A31227",
      "code_information": [
        {
          "code": "3397818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 78.9662,
          "maximum": 226.4184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.3049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-SKIN DERMABOND  DNX12",
      "code_information": [
        {
          "code": "3500034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 99.5419,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SOFTGOODS CPM        20533",
      "code_information": [
        {
          "code": "3500038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 46.1563,
          "maximum": 235.8525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.9843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "3500087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.4145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LMA DISP ALL SZ  1250xx",
      "code_information": [
        {
          "code": "3500245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 91.7565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 34FR  123034",
      "code_information": [
        {
          "code": "3500275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 38.3709,
          "maximum": 119.7405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.1613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 28F   123028",
      "code_information": [
        {
          "code": "3500280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 26FR  123026",
      "code_information": [
        {
          "code": "3500283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 30FR  123030",
      "code_information": [
        {
          "code": "3500285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 32FR  123032",
      "code_information": [
        {
          "code": "3500288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACMENT KNEE COLD L/XL",
      "code_information": [
        {
          "code": "3500410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 7.7854,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP   260815",
      "code_information": [
        {
          "code": "3500759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 127,
          "minimum": 43.4168,
          "maximum": 243.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.7908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED & 60MM AIRWAY",
      "code_information": [
        {
          "code": "3500786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT & 90MM AIRWY",
      "code_information": [
        {
          "code": "3500788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 38.927,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.4936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASPIRATOR-MECONIUM HCI   N0101",
      "code_information": [
        {
          "code": "3500789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 88.4199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-INFANT  5442160xx",
      "code_information": [
        {
          "code": "3500792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 42.8197,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-COLLECTION 4X8 BX     9778",
      "code_information": [
        {
          "code": "3500815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 55.8789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    C0135T",
      "code_information": [
        {
          "code": "3501012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 7.7854,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.4203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0        697H",
      "code_information": [
        {
          "code": "3501065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 57.3303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 FS-3  1665G",
      "code_information": [
        {
          "code": "3501070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 249.1328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXTERNAL CSF DRAIN INS8700",
      "code_information": [
        {
          "code": "3501130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 448,
          "minimum": 99.5419,
          "maximum": 325.1136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.1045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC VERALNK ULTLNK500",
      "code_information": [
        {
          "code": "3501755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 666,
          "minimum": 83.415,
          "maximum": 483.3162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 444.6509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18FR5CC 0119L18",
      "code_information": [
        {
          "code": "3501790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 31.6977,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC       6261",
      "code_information": [
        {
          "code": "3502002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 91.2004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EFFLUENT 5L PRISMAFLEX",
      "code_information": [
        {
          "code": "3502007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.4936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 20F30C  0167L20",
      "code_information": [
        {
          "code": "3502010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 205.2009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL   TCS1000",
      "code_information": [
        {
          "code": "3502048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 369,
          "minimum": 60.0588,
          "maximum": 267.7833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 246.3606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 400     7000LL",
      "code_information": [
        {
          "code": "3502063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 1283.4788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST MED RIGHT 5001-0",
      "code_information": [
        {
          "code": "3502580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 118.2891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 108.826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LARGE RT  5001-04",
      "code_information": [
        {
          "code": "3502590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 704.0226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 108.826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-LIFEBAND FOR AUTOPULSE",
      "code_information": [
        {
          "code": "3502593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1266,
          "minimum": 93.4248,
          "maximum": 918.7362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 845.2373,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST X-LG LT 5001-10",
      "code_information": [
        {
          "code": "3502600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.1642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-FLEXMASTER 6\\\" 79-98718",
      "code_information": [
        {
          "code": "3502681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 304.1867,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.4965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF C",
      "code_information": [
        {
          "code": "3502706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 547,
          "minimum": 187.0001,
          "maximum": 396.9579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 365.2013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF D",
      "code_information": [
        {
          "code": "3502707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 475,
          "minimum": 162.3858,
          "maximum": 344.7075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 317.1309,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-BUNNY W/FRAME & LINER",
      "code_information": [
        {
          "code": "3502709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 351,
          "minimum": 119.9946,
          "maximum": 254.7207,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 234.343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-LEG FULL SM 9128-01",
      "code_information": [
        {
          "code": "3502720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 345,
          "minimum": 90.6443,
          "maximum": 250.3665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 230.3372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3502751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 47.2685,
          "maximum": 118.2891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 108.826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMIN 46-62 13992000",
      "code_information": [
        {
          "code": "3503080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 377.5919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-HOOD ALL  0408-8xx-000",
      "code_information": [
        {
          "code": "3503348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 679,
          "minimum": 35.5904,
          "maximum": 492.7503,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 453.3303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ENV INFANT   8004-01",
      "code_information": [
        {
          "code": "3503370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 686.2274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT ARM",
      "code_information": [
        {
          "code": "3504148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.1261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT BOOT",
      "code_information": [
        {
          "code": "3504149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.1261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT FULL LENGTH",
      "code_information": [
        {
          "code": "3504150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 88.5354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 81.4526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED ARM",
      "code_information": [
        {
          "code": "3504151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED BOOT",
      "code_information": [
        {
          "code": "3504152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER EYE        607120",
      "code_information": [
        {
          "code": "3504353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 96.7614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MAC 3&4",
      "code_information": [
        {
          "code": "3504355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 126.2718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.1701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MIL 2&3",
      "code_information": [
        {
          "code": "3504357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 126.2718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.1701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "3504552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 96.5181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1.5\\\" CT\\\"",
      "code_information": [
        {
          "code": "3504553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 181.2886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM      100 1974",
      "code_information": [
        {
          "code": "3504663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 326,
          "minimum": 45.0441,
          "maximum": 236.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 217.6519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM     12-7 1972",
      "code_information": [
        {
          "code": "3504665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CHANNELED         KVL03C",
      "code_information": [
        {
          "code": "3504905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST EZWALK XL 2001-05",
      "code_information": [
        {
          "code": "3505035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 35.5904,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST STAT ALL 2001-00s",
      "code_information": [
        {
          "code": "3505545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 55.0539,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA TENDERWRAP 4\\\"X10YDS",
      "code_information": [
        {
          "code": "3505570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 156.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WAFFLE  ALL SIZES    FW's",
      "code_information": [
        {
          "code": "3505575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 187.608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2515H****",
      "code_information": [
        {
          "code": "3505815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 4263.0626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 69.435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICAL MED",
      "code_information": [
        {
          "code": "3505906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 83.4555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE HEAVY LARGE",
      "code_information": [
        {
          "code": "3505907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 74.7471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE CHILD   3004-12",
      "code_information": [
        {
          "code": "3505955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 1675.5293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION ATEC",
      "code_information": [
        {
          "code": "3506118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3506181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-7FR \\\"SLIC\\\"       SC-14701",
      "code_information": [
        {
          "code": "3506470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.1378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CURITY ULTRAMER 6FR  6006",
      "code_information": [
        {
          "code": "3506758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 22G   383591",
      "code_information": [
        {
          "code": "3507108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 90.7125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.4555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 24G   383590",
      "code_information": [
        {
          "code": "3507111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 111.7761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.4555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW ARTERIAL VENOUS",
      "code_information": [
        {
          "code": "3507185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.1964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3W 16F 5CC  0119L16",
      "code_information": [
        {
          "code": "3507187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 101.598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.4702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 30CC ALL 123600As",
      "code_information": [
        {
          "code": "3507190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 31.1416,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.1261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 12 5 165812",
      "code_information": [
        {
          "code": "3507192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 14 5 165814",
      "code_information": [
        {
          "code": "3507193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 16 5 165816",
      "code_information": [
        {
          "code": "3507194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 18 5 165818",
      "code_information": [
        {
          "code": "3507195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 20 5 165820",
      "code_information": [
        {
          "code": "3507196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 22 5 165822",
      "code_information": [
        {
          "code": "3507197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 24 5 165824",
      "code_information": [
        {
          "code": "3507198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 144.586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18F 0125RL18",
      "code_information": [
        {
          "code": "3507371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 260,
          "minimum": 81.1906,
          "maximum": 188.682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 173.5874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 20F 30C W/V  0125RL20",
      "code_information": [
        {
          "code": "3507373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 105.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 22FR/30CC",
      "code_information": [
        {
          "code": "3507381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 146.2543,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 24F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 190.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 175.5904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 26F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 36.7026,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 20FR 30CC      266720",
      "code_information": [
        {
          "code": "3507665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.0645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 24FR 30CC      266724",
      "code_information": [
        {
          "code": "3507670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3CC   8887603101",
      "code_information": [
        {
          "code": "3507688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 7.7854,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W  8F  3CC   8887603085",
      "code_information": [
        {
          "code": "3507852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 165.1617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-OXIMETRY 5 LUMEN  5032805",
      "code_information": [
        {
          "code": "3508302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1222,
          "minimum": 399.8359,
          "maximum": 886.8054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 815.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SOAKER 1\\\"           PM030",
      "code_information": [
        {
          "code": "3508888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 719,
          "minimum": 90.6443,
          "maximum": 521.7783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 480.036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-20X1.5 RADIO ARTE RA04220",
      "code_information": [
        {
          "code": "3509147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 32.2538,
          "maximum": 130.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.1759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 16FR  010116",
      "code_information": [
        {
          "code": "3509269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 14FR  010114",
      "code_information": [
        {
          "code": "3509270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN STRAIGHT 18FR",
      "code_information": [
        {
          "code": "3509305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 125.6786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-CHEST DRAIN 9.6FR",
      "code_information": [
        {
          "code": "3509905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 82.8589,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.9198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP ADJ     AA11",
      "code_information": [
        {
          "code": "3509911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 149,
          "minimum": 50.9379,
          "maximum": 108.1293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-LOW TEMP ADJ      AA02",
      "code_information": [
        {
          "code": "3509912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3510001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.8641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COA 04273",
      "code_information": [
        {
          "code": "3510002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3510099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.5229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEX 72\\\"   DF47x-6121Z",
      "code_information": [
        {
          "code": "3510143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 104.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENTILATOR COAX",
      "code_information": [
        {
          "code": "3510148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLEANSER-BODY FOAMING REMEDY",
      "code_information": [
        {
          "code": "3510305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCLIP-MEDIUM         523800",
      "code_information": [
        {
          "code": "3510401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.1349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL SMALL 710-SMAL",
      "code_information": [
        {
          "code": "3510714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.8377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL MEDIUM 710-MED",
      "code_information": [
        {
          "code": "3510715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 125.5461,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.5024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK PEDI-SELE",
      "code_information": [
        {
          "code": "3510817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL ALL SZ A11500x",
      "code_information": [
        {
          "code": "3510830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3511220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 66.732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 34.7175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y PRISMAFLEX",
      "code_information": [
        {
          "code": "3511240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.1173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISP F/NEOBLUE COZY",
      "code_information": [
        {
          "code": "3511668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.4203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FOOT PNEU LRG PR  VP520L",
      "code_information": [
        {
          "code": "3511672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 99.4209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.4672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FT PNEU REGULAR PR VP520",
      "code_information": [
        {
          "code": "3511673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.1173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE LTX-FREE   610-002",
      "code_information": [
        {
          "code": "3511677",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 85.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT MED LF/ALUM  7703",
      "code_information": [
        {
          "code": "3511781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 111.7578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.8172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-YOUTH LF/ALUM      7702",
      "code_information": [
        {
          "code": "3511795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 169.0544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3511958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 202.9638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB TALL",
      "code_information": [
        {
          "code": "3511962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 202.9638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FOAM W/COVER    154264",
      "code_information": [
        {
          "code": "3512506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 211,
          "minimum": 72.1335,
          "maximum": 153.1227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.8729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 16-18FR",
      "code_information": [
        {
          "code": "3512575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.8142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.1CM 9231",
      "code_information": [
        {
          "code": "3512760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.1349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.2CM 9232",
      "code_information": [
        {
          "code": "3512761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 131,
          "minimum": 44.7843,
          "maximum": 95.0667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.4614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ANCHOR PICC LNE PIC0220",
      "code_information": [
        {
          "code": "3512770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.0704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 PED PEDI CAP",
      "code_information": [
        {
          "code": "3512773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 722.93,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.5024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RESQPOD 029-12-0242-000",
      "code_information": [
        {
          "code": "3512775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 867.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FEMOSTOP         11165",
      "code_information": [
        {
          "code": "3512782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 97.3175,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH STABILIZ    DIO120",
      "code_information": [
        {
          "code": "3512792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.8377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH SECURMENT VPPDFP",
      "code_information": [
        {
          "code": "3512794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 82.8589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL  SMALL  S-22MM",
      "code_information": [
        {
          "code": "3513121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 149,
          "minimum": 50.9379,
          "maximum": 108.1293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL MEDIUM  M-29MM",
      "code_information": [
        {
          "code": "3513123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 921.4577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.4965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-ACCU ANTI-REFLUX INS8401",
      "code_information": [
        {
          "code": "3513202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1657,
          "minimum": 215.7668,
          "maximum": 1202.4849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1106.2861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST VALVE PNEUMOSTAT",
      "code_information": [
        {
          "code": "3513225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 40.0392,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.0459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT PRATT        SU130s",
      "code_information": [
        {
          "code": "3513231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.0704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE W/ISO BAG    1003",
      "code_information": [
        {
          "code": "3513475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 108.4395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM SM SIMP CS",
      "code_information": [
        {
          "code": "3514025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 414,
          "minimum": 141.5321,
          "maximum": 300.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 276.4046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM BRIDGE",
      "code_information": [
        {
          "code": "3514230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 640,
          "minimum": 204.0887,
          "maximum": 464.448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 427.2922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-PREVENA 45ML",
      "code_information": [
        {
          "code": "3514251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 367,
          "minimum": 125.4644,
          "maximum": 266.3319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 245.0253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC 500ML WITH GEL",
      "code_information": [
        {
          "code": "3514255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 413,
          "minimum": 141.1902,
          "maximum": 299.7141,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 275.737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO MED",
      "code_information": [
        {
          "code": "3514259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1213,
          "minimum": 414.6821,
          "maximum": 880.2741,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 809.8522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO SM",
      "code_information": [
        {
          "code": "3514261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 30.5855,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYME 4X4 5044",
      "code_information": [
        {
          "code": "3514264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 106.2151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM     10X15CM",
      "code_information": [
        {
          "code": "3514272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 138.6087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 127.52,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDITRACE 31319281**",
      "code_information": [
        {
          "code": "3514650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 917.0089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5FR   006173P",
      "code_information": [
        {
          "code": "3514812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1649,
          "minimum": 116.781,
          "maximum": 1196.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1100.945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-REDIPAK",
      "code_information": [
        {
          "code": "3514819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 210,
          "minimum": 71.7916,
          "maximum": 152.397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLOOD        SQ40S",
      "code_information": [
        {
          "code": "3516138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 97.3175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.7879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTERLINE-INTUBATED SET 185",
      "code_information": [
        {
          "code": "3516160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 891.4283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.8377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-MR 9GX14CM 20MM",
      "code_information": [
        {
          "code": "3518855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2344,
          "minimum": 318.6453,
          "maximum": 1701.0408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1564.9575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX16CM",
      "code_information": [
        {
          "code": "3518857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 382.56,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX1xCM",
      "code_information": [
        {
          "code": "3518865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 382.56,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX1xCM",
      "code_information": [
        {
          "code": "3518868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX10CM",
      "code_information": [
        {
          "code": "3518870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 578,
          "minimum": 56.7222,
          "maximum": 419.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 385.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1962",
      "code_information": [
        {
          "code": "3519300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1034,
          "minimum": 46.7124,
          "maximum": 750.3738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 690.3439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS LF ADLT",
      "code_information": [
        {
          "code": "3519395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.0821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUGGER-HEART STERNUM ALL 1000s",
      "code_information": [
        {
          "code": "3519770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 83.9711,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.4055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 12F 36\\\"",
      "code_information": [
        {
          "code": "3520193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.7937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 20F 5CC",
      "code_information": [
        {
          "code": "3520196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 129.5713,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 102.8172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 22FR 20CC",
      "code_information": [
        {
          "code": "3520199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 55.61,
          "maximum": 169.0881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 155.5611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INHALER-DIAMOND SPACR 107-9830",
      "code_information": [
        {
          "code": "3520701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.7644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-INTUBATION ALL Gs",
      "code_information": [
        {
          "code": "3521014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1015,
          "minimum": 124.0103,
          "maximum": 736.5855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 677.6587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BARRIER MINOR PROTECTIVE",
      "code_information": [
        {
          "code": "3521441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.4936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT FEMORAL 111644",
      "code_information": [
        {
          "code": "3521442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 115.1127,
          "maximum": 309.1482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 284.4163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACOSTOMY PROC ******",
      "code_information": [
        {
          "code": "3521523",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 207,
          "minimum": 70.766,
          "maximum": 664.5395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.2023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH CVP SL       AK-24301",
      "code_information": [
        {
          "code": "3521655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 1142.2294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRAINAL ACCESS    INS-5HND",
      "code_information": [
        {
          "code": "3521683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2054,
          "minimum": 207.4253,
          "maximum": 1490.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1371.3408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DAILY CARE            6638",
      "code_information": [
        {
          "code": "3521745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.0704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAINAGE PLEURX    50-7510",
      "code_information": [
        {
          "code": "3521755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 43.9319,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 550.1387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DURAPREP SURGICAL     8630",
      "code_information": [
        {
          "code": "3521756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 996.5312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HYPOTHERMIA \\\"KOOL KIT\\\" 900",
      "code_information": [
        {
          "code": "3521917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1792,
          "minimum": 226.3327,
          "maximum": 1300.4544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1196.418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 6FR AK-09601***",
      "code_information": [
        {
          "code": "3521942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 407,
          "minimum": 139.139,
          "maximum": 295.3599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 271.7311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 8.5 AK-09803CDC",
      "code_information": [
        {
          "code": "3521947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 628,
          "minimum": 43.9319,
          "maximum": 455.7396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 419.2804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGAT CONE/TUBE BX  7721",
      "code_information": [
        {
          "code": "3521963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-SARAH 2778 ALL SIZES",
      "code_information": [
        {
          "code": "3522000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 505,
          "minimum": 142.3616,
          "maximum": 366.4785,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 337.1602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-HANNAH 2160 ALL SIZES",
      "code_information": [
        {
          "code": "3522002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 256,
          "minimum": 87.5174,
          "maximum": 185.7792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.9169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K ALL SIZES",
      "code_information": [
        {
          "code": "3522003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 98.4571,
          "maximum": 707.3592,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LUMBAR PUNCTURE    4011015",
      "code_information": [
        {
          "code": "3522152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 178.9286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MAC CATH MULTI AK-21242CDC",
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        {
          "code": "3522182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1364,
          "minimum": 392.6066,
          "maximum": 989.8548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 910.6664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 20FR         6820",
      "code_information": [
        {
          "code": "3522270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 471.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00568241",
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        {
          "code": "3522271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 471.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KOOL NEONATAL 950",
      "code_information": [
        {
          "code": "3522460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1169,
          "minimum": 399.64,
          "maximum": 848.3433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 780.4758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING ALL",
      "code_information": [
        {
          "code": "3522465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 249.1328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.7937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-MORGAN LTX-FREE    MT2000",
      "code_information": [
        {
          "code": "3522687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 448,
          "minimum": 40.0392,
          "maximum": 325.1136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 299.1045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-4-WAY         4238701",
      "code_information": [
        {
          "code": "3523121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.0704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND PREMATURE 900643",
      "code_information": [
        {
          "code": "3523139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND MICRO     900644",
      "code_information": [
        {
          "code": "3523140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 50MM    RD805-10",
      "code_information": [
        {
          "code": "3523187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 101,
          "minimum": 34.5284,
          "maximum": 2159.8924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 67.432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MITT-HAND CONTROL PR  M2023V-A",
      "code_information": [
        {
          "code": "3523675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 69.7404,
          "maximum": 365.3577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.1994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTRAOSSEOUS ORANGE",
      "code_information": [
        {
          "code": "3523854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATN     ALL 7700's",
      "code_information": [
        {
          "code": "3523864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 309.1482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 284.4163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX11C",
      "code_information": [
        {
          "code": "3525447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 144.0299,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X13.8 C1616A",
      "code_information": [
        {
          "code": "3525465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 88.543,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.9198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X7.8  C1610A",
      "code_information": [
        {
          "code": "3525466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X7.8  C2010A",
      "code_information": [
        {
          "code": "3525467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "3525468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 352.5674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL STR 17GX4-1/2\\\"",
      "code_information": [
        {
          "code": "3525873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 73.9613,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 20G X 1\\\"",
      "code_information": [
        {
          "code": "3525882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 476.5777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS G04153",
      "code_information": [
        {
          "code": "3525915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 857,
          "minimum": 136.2445,
          "maximum": 621.9249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 572.1709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-4   DJ4011X",
      "code_information": [
        {
          "code": "3525924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 43.9319,
          "maximum": 177.7965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 163.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL PENCAN    333866",
      "code_information": [
        {
          "code": "3525950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 67.8442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX5\\\"    405148",
      "code_information": [
        {
          "code": "3525951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 88.5354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 81.4526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX7\\\"    405149",
      "code_information": [
        {
          "code": "3525960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X22G",
      "code_information": [
        {
          "code": "3525975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 74.7471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X25G",
      "code_information": [
        {
          "code": "3525976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 418.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PROBLOC 20X100 HN3S-100",
      "code_information": [
        {
          "code": "3526110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 679.5542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E CATH PLUS 241285-41E",
      "code_information": [
        {
          "code": "3526122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 467,
          "minimum": 159.6509,
          "maximum": 537.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 311.7897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PULSAVAC 00-5150-182-00",
      "code_information": [
        {
          "code": "3526127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.1261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL EXTEND 480422",
      "code_information": [
        {
          "code": "3526149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3703,
          "minimum": 1265.9256,
          "maximum": 4248.604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2472.2857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-AIRWAY EMMA 17448",
      "code_information": [
        {
          "code": "3526175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 166,
          "minimum": 56.7496,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.8289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.5/2.8",
      "code_information": [
        {
          "code": "3526179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1520,
          "minimum": 464.8996,
          "maximum": 1103.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1014.8189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO xxXxxMM 2.0",
      "code_information": [
        {
          "code": "3526182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.6792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 5800-8-125",
      "code_information": [
        {
          "code": "3526187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1120,
          "minimum": 382.8886,
          "maximum": 812.784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 747.7613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.3MM TWIST QC",
      "code_information": [
        {
          "code": "3526189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 132.3518,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT,-NIFOMETER 10-340-03",
      "code_information": [
        {
          "code": "3526194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 238,
          "minimum": 63.3954,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 158.8993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-NASAL AUTOMATION MAD300",
      "code_information": [
        {
          "code": "3526195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 70143061",
      "code_information": [
        {
          "code": "3526216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 63.5869,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 124.1818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT BUTTERFLY 240073",
      "code_information": [
        {
          "code": "3526217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 646.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER SB4000SA",
      "code_information": [
        {
          "code": "3526218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1162,
          "minimum": 397.247,
          "maximum": 843.2634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 775.8023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SB4040SC",
      "code_information": [
        {
          "code": "3526219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1298,
          "minimum": 443.7406,
          "maximum": 941.9586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 866.6019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MALLEABLE MS4000SC",
      "code_information": [
        {
          "code": "3526220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1330,
          "minimum": 99.5419,
          "maximum": 965.181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 887.9665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y936H",
      "code_information": [
        {
          "code": "3526223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 2691.524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CANNULATED 2.0X120MM",
      "code_information": [
        {
          "code": "3526239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1136,
          "minimum": 388.3585,
          "maximum": 9117.8156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 758.4436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICYRL-4-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 7.7854,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X36",
      "code_information": [
        {
          "code": "3526256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 56.7222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X96",
      "code_information": [
        {
          "code": "3526257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 74.0214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.0997,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-0 PDS PLUS 1X60",
      "code_information": [
        {
          "code": "3526258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 12X18",
      "code_information": [
        {
          "code": "3526259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-4-0 PLUS 1X18",
      "code_information": [
        {
          "code": "3526264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRILL 2.0 SPEED HAND WRIS",
      "code_information": [
        {
          "code": "3526271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2796,
          "minimum": 955.8541,
          "maximum": 2855.0174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1866.7326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM ANTERIOR",
      "code_information": [
        {
          "code": "3526278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 595,
          "minimum": 203.4096,
          "maximum": 1055.4778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 397.2482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM     70890832",
      "code_information": [
        {
          "code": "3526280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 119,
          "minimum": 40.6819,
          "maximum": 225.7766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 79.4496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT LMA ALL SIZE",
      "code_information": [
        {
          "code": "3526297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURAGAIN SIZE 4",
      "code_information": [
        {
          "code": "3526298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 592.2465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREADED AR-13226T",
      "code_information": [
        {
          "code": "3526314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 930,
          "minimum": 317.9343,
          "maximum": 5759.5277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 620.9089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BATTERY 1.5 50-1010",
      "code_information": [
        {
          "code": "3526343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 919,
          "minimum": 99.5419,
          "maximum": 666.9183,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 613.5648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC SUPER AK-24301-SK",
      "code_information": [
        {
          "code": "3526356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 684,
          "minimum": 233.8356,
          "maximum": 526.0706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 456.6685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY 351-3500SZ",
      "code_information": [
        {
          "code": "3526357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 946,
          "minimum": 323.4042,
          "maximum": 53870.5192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 631.5912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 115” Y 1637101",
      "code_information": [
        {
          "code": "3526361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 438.7629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.7879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LITHOTOMY DYNJ31774G",
      "code_information": [
        {
          "code": "3526362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 789,
          "minimum": 269.7314,
          "maximum": 705.6909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 526.7711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER CLOSED 4MM STRT",
      "code_information": [
        {
          "code": "3526366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1269,
          "minimum": 433.8265,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 847.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER XPEEDA AC-1000729",
      "code_information": [
        {
          "code": "3526375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAL, X",
      "code_information": [
        {
          "code": "3526388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 528,
          "minimum": 180.5046,
          "maximum": 383.1696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 352.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAl LG",
      "code_information": [
        {
          "code": "3526389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 528,
          "minimum": 180.5046,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 352.516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-METATRSAL 20MM",
      "code_information": [
        {
          "code": "3526404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 757.4082,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2016.2849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.2X1.8X87MM",
      "code_information": [
        {
          "code": "3526414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CANN 2.2 A-2716",
      "code_information": [
        {
          "code": "3526415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2846,
          "minimum": 75.0735,
          "maximum": 2065.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1900.1148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 20GX6 405211",
      "code_information": [
        {
          "code": "3526416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 486.5875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL 7 SP-78107",
      "code_information": [
        {
          "code": "3526419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1023,
          "minimum": 349.7278,
          "maximum": 742.3911,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 682.9998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-GEN VASCULAR DYNJ60177",
      "code_information": [
        {
          "code": "3526422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1556,
          "minimum": 531.9417,
          "maximum": 1129.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1038.8541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC SIE DYNJ905699",
      "code_information": [
        {
          "code": "3526423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1952,
          "minimum": 667.3202,
          "maximum": 1416.5664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1303.2411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO SHOULDER DYNJ60141",
      "code_information": [
        {
          "code": "3526425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 262.2103,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 512.0829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO KNEE DYNJ60140",
      "code_information": [
        {
          "code": "3526428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 209.905,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 409.9334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-LOW FLOW,DISP PATIENT",
      "code_information": [
        {
          "code": "3526443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.6469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HIGH FLOW, DISP PT'",
      "code_information": [
        {
          "code": "3526445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1053,
          "minimum": 35.0343,
          "maximum": 764.1621,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 703.0291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SMALL PED NASAL OXYGEN",
      "code_information": [
        {
          "code": "3526446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 45.7191,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.0616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-PED/ADULT SM – MP1500",
      "code_information": [
        {
          "code": "3526447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 45.7191,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.0616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIGH FLOW ADULT MA1700",
      "code_information": [
        {
          "code": "3526449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 11710.9099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INFANT OVER THE EAR",
      "code_information": [
        {
          "code": "3526455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 121.7859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORPEDO-4.0MM X13 CM AR-8400T",
      "code_information": [
        {
          "code": "3526458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 930,
          "minimum": 317.9343,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 620.9089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ABLATOR-ASPIRATING AR-8921",
      "code_information": [
        {
          "code": "3526459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 99.5419,
          "maximum": 985.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 906.6606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR COLD 10MM Rnd",
      "code_information": [
        {
          "code": "3526467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 187.608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-OVAL FLUSH-CUT AR-8550FOS",
      "code_information": [
        {
          "code": "3526471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 526.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOLVE-CUT RESIST XL520036000",
      "code_information": [
        {
          "code": "3526473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 281.6966,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 550.1387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE/BLACK 1.5MM",
      "code_information": [
        {
          "code": "3526474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 558.1504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-90 DEG APOLLO AR-9811",
      "code_information": [
        {
          "code": "3526476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 985.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 906.6606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELITE IRRIG 5407010470",
      "code_information": [
        {
          "code": "3526484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 518.0917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 12 DPSB 60707010200",
      "code_information": [
        {
          "code": "3526492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.9433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPSB 60707010300",
      "code_information": [
        {
          "code": "3526493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.9726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPSB 60707010400",
      "code_information": [
        {
          "code": "3526494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 260.8109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 232.3401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPDB 60708010300",
      "code_information": [
        {
          "code": "3526495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 340.3533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 260715",
      "code_information": [
        {
          "code": "3526503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TUBING MXB-T",
      "code_information": [
        {
          "code": "3526520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 506,
          "minimum": 172.9836,
          "maximum": 1638.8267,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 337.8279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-FLOTRAX PERFUSION 84\\\" M",
      "code_information": [
        {
          "code": "3526525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2947,
          "minimum": 497.7095,
          "maximum": 2138.6379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1967.5469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT YG-272T",
      "code_information": [
        {
          "code": "3526528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 1475.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.8582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.5MMX13CM AR-8550EX",
      "code_information": [
        {
          "code": "3526571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.1104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BULLET CUTTING 3MM",
      "code_information": [
        {
          "code": "3526591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2519,
          "minimum": 861.1576,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1681.7952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MAJOR HEAD/NEC DYNJ38985A",
      "code_information": [
        {
          "code": "3526665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 696,
          "minimum": 237.9379,
          "maximum": 1426.9526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 464.6802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-BIOPATCH CHG 1”X4MM 4150",
      "code_information": [
        {
          "code": "3526904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 10956.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-JAW TISSUE ENSEAL LRG",
      "code_information": [
        {
          "code": "3526926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2829,
          "minimum": 967.1357,
          "maximum": 3864.895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1888.7649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT SMALL",
      "code_information": [
        {
          "code": "3526929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 571,
          "minimum": 195.2048,
          "maximum": 414.3747,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.2247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT LARGE",
      "code_information": [
        {
          "code": "3526930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 660,
          "minimum": 225.6308,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 440.645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A443",
      "code_information": [
        {
          "code": "3526935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 393,
          "minimum": 134.3529,
          "maximum": 285.2001,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.3841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A445",
      "code_information": [
        {
          "code": "3526936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.0459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFX 2-0 SXMP1B413",
      "code_information": [
        {
          "code": "3526938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 352,
          "minimum": 120.3364,
          "maximum": 336.9966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 235.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4FUSION 2.0 CALIBRATED",
      "code_information": [
        {
          "code": "3526943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1113,
          "minimum": 380.4956,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 743.0878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-AFFINITY MANIFOLD 1S85R1",
      "code_information": [
        {
          "code": "3526965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COMP SPEEDARC 11X15X13MM",
      "code_information": [
        {
          "code": "3526978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5134,
          "minimum": 1755.1342,
          "maximum": 3725.7438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3427.6843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7.5CM POST",
      "code_information": [
        {
          "code": "3526995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 608,
          "minimum": 207.8538,
          "maximum": 1044.9119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 405.9276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING DISP EXT 5450850003",
      "code_information": [
        {
          "code": "3526996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1879,
          "minimum": 233.0059,
          "maximum": 1363.5903,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1254.5031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINDER-DISP SUCT CAN",
      "code_information": [
        {
          "code": "3526997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 419,
          "minimum": 143.2414,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.7428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIAMETER-STRAIGHT 5450800309",
      "code_information": [
        {
          "code": "3526999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3756,
          "minimum": 1284.0444,
          "maximum": 2725.7292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2507.6709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRICOTHYROIDOTOMY EMERGENT",
      "code_information": [
        {
          "code": "3527020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1028,
          "minimum": 310.3038,
          "maximum": 746.0196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 686.338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-2.7MM 311.26",
      "code_information": [
        {
          "code": "3527056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 864,
          "minimum": 295.3712,
          "maximum": 627.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 576.8444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.15, 1.5MM",
      "code_information": [
        {
          "code": "3527057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 283.0641,
          "maximum": 600.8796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 552.8092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.19, 2.0MM",
      "code_information": [
        {
          "code": "3527058",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 849,
          "minimum": 290.2433,
          "maximum": 1353.5474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 566.8298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X .75”",
      "code_information": [
        {
          "code": "3527066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 4611.1812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.35X50X101MM",
      "code_information": [
        {
          "code": "3527084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 2087.0433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.6792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PICK-VEIN 6541",
      "code_information": [
        {
          "code": "3527102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.0/2.3",
      "code_information": [
        {
          "code": "3527119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1520,
          "minimum": 519.6346,
          "maximum": 1103.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1014.8189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO",
      "code_information": [
        {
          "code": "3527121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 53.9417,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.6792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BRUSH ALGER 0.5MM",
      "code_information": [
        {
          "code": "3527123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.7615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOPATCH-DRESS CHG 1” X 7MM",
      "code_information": [
        {
          "code": "3527124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 2416.2545,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLENOID DRILL 2.5MM",
      "code_information": [
        {
          "code": "3527142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8074,
          "minimum": 2760.2169,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5390.5577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD WIDE MT-APUW",
      "code_information": [
        {
          "code": "3527145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 311.1221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLUS-VIVAER ARC DISP CAT500",
      "code_information": [
        {
          "code": "3527147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9026,
          "minimum": 870.8526,
          "maximum": 6550.1682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6026.1547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-KEITH FREE 1827-2.5DC",
      "code_information": [
        {
          "code": "3527159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3MM AR-8930D-13",
      "code_information": [
        {
          "code": "3527163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 83.415,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-GONIO SURG OSIG",
      "code_information": [
        {
          "code": "3527169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 4705.7182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO V4608-20",
      "code_information": [
        {
          "code": "3527175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 69.435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 3.2X125MM GRAY",
      "code_information": [
        {
          "code": "3527179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1195,
          "minimum": 408.5285,
          "maximum": 1627.1486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 797.8346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-POSEY SECURE INFANT PED",
      "code_information": [
        {
          "code": "3527200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 389,
          "minimum": 132.9854,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.7135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-INDIGO 140CM CATRXKIT",
      "code_information": [
        {
          "code": "3527201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8123,
          "minimum": 2588.0894,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5423.2722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPERATOR-C4 PENUMBRA SEPC4",
      "code_information": [
        {
          "code": "3527202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4654,
          "minimum": 1343.5376,
          "maximum": 3377.4078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3107.2152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENGINE INDIGO IAPS3",
      "code_information": [
        {
          "code": "3527203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 259.1426,
          "maximum": 1753.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1613.0279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRVO2-TUBE CHAMBER KIT, 900PT",
      "code_information": [
        {
          "code": "3527205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 730,
          "minimum": 249.5613,
          "maximum": 5082.1979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 487.3801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN W/AO 5.0MM",
      "code_information": [
        {
          "code": "3527232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 9536.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 325.8103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-QUICK CONN DRVR-UQC-T10",
      "code_information": [
        {
          "code": "3527241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1399,
          "minimum": 478.2689,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 934.034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7X70MM IJS-CDC-2770",
      "code_information": [
        {
          "code": "3527242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2785,
          "minimum": 952.0936,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1859.3885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSSEPTAL NTK-711-8545",
      "code_information": [
        {
          "code": "3527245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 81.1906,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERES-PASSIVE 8801075",
      "code_information": [
        {
          "code": "3527246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.9X10X61MM",
      "code_information": [
        {
          "code": "3527253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.6792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DRILL SELF HOLD",
      "code_information": [
        {
          "code": "3527257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2110,
          "minimum": 721.3349,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1408.7288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE 108984",
      "code_information": [
        {
          "code": "3527264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 374.5483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO MICRO 0",
      "code_information": [
        {
          "code": "3527266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 649,
          "minimum": 221.8703,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 433.301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3527268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5424,
          "minimum": 311.9721,
          "maximum": 3936.1968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3621.3011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-STERILE PGH 396985",
      "code_information": [
        {
          "code": "3527269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 374.5483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-BS IS-1 330834",
      "code_information": [
        {
          "code": "3527270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 7MM, 70X",
      "code_information": [
        {
          "code": "3527281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 472.0243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-301-CG 343586",
      "code_information": [
        {
          "code": "3527282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 374.5483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIDER TS101DC",
      "code_information": [
        {
          "code": "3527287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 594,
          "minimum": 99.5419,
          "maximum": 431.0658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 396.5805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM 7089-0832",
      "code_information": [
        {
          "code": "3527289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 88.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.1085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 1.27MM",
      "code_information": [
        {
          "code": "3527290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 5375.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER DS2C026",
      "code_information": [
        {
          "code": "3527342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4316,
          "minimum": 208.5375,
          "maximum": 3132.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2881.5515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ALLEN 3.0MM 904-0030",
      "code_information": [
        {
          "code": "3527343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 375,
          "minimum": 128.1993,
          "maximum": 4835.2895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 250.3665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3527395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 97.9695,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAXI-THERM LITE 871*******",
      "code_information": [
        {
          "code": "3527520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.4145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-CALAZIME REMEDY 4 OZ",
      "code_information": [
        {
          "code": "3527567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 1897.9693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-K SOFT 117464",
      "code_information": [
        {
          "code": "3527806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 60-S FIRM 119291",
      "code_information": [
        {
          "code": "3527807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 374.5483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-C MEDIUM 342657",
      "code_information": [
        {
          "code": "3527808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 11365.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 03.033.004",
      "code_information": [
        {
          "code": "3527874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 109.5517,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-INFANT POSITIONER",
      "code_information": [
        {
          "code": "3527875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 27745.4973,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 131.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CRM DYNJ62070",
      "code_information": [
        {
          "code": "3527887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 756,
          "minimum": 258.4498,
          "maximum": 548.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 504.7389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-INFANT FULL BODY",
      "code_information": [
        {
          "code": "3527890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1059,
          "minimum": 362.0349,
          "maximum": 970.9506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 707.035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNCK SLCT980010",
      "code_information": [
        {
          "code": "3527947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-IRR SUCT 5500-573-000",
      "code_information": [
        {
          "code": "3527977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3127,
          "minimum": 331.9917,
          "maximum": 2269.2639,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2087.7228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION 5450-851-012",
      "code_information": [
        {
          "code": "3527978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 2832.7734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MICRO-IQ 12CM 5500-25S-309",
      "code_information": [
        {
          "code": "3527979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5094,
          "minimum": 1741.4596,
          "maximum": 3696.7158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3400.9785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STD-12CM 5500-25S-307",
      "code_information": [
        {
          "code": "3527980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4754,
          "minimum": 1625.2255,
          "maximum": 3449.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3173.9796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRACUDA-12CM IQ 5500-25S-310",
      "code_information": [
        {
          "code": "3527981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5201,
          "minimum": 317.5331,
          "maximum": 3774.3657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3472.4164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-APEX 11CM 5500-25B-114",
      "code_information": [
        {
          "code": "3527983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 342.0015,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND ROYLAN RT MED",
      "code_information": [
        {
          "code": "3528086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 1014.8825,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORTHOSIS-ANKLE FOOT LG",
      "code_information": [
        {
          "code": "3528101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 704,
          "minimum": 240.6729,
          "maximum": 720.1495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 470.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 30 DPSB 60707010500",
      "code_information": [
        {
          "code": "3529495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 248.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPDB 60708010200",
      "code_information": [
        {
          "code": "3529498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 428,
          "minimum": 146.3182,
          "maximum": 354.2357,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 285.7516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SINGLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 637,
          "minimum": 217.7679,
          "maximum": 462.2709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 425.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST DOUBLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 468,
          "minimum": 159.9928,
          "maximum": 430.4214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 312.4574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #4     4DCP",
      "code_information": [
        {
          "code": "3533309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #6,8,10 DCP",
      "code_information": [
        {
          "code": "3533315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SKIN TEMP DISP MU11228",
      "code_information": [
        {
          "code": "3533577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.5229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP ISOLETTE    MU12551",
      "code_information": [
        {
          "code": "3533578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 238,
          "minimum": 51.1612,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 158.8993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-RECTAL/ESOPH ST     491B",
      "code_information": [
        {
          "code": "3533590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTANT-SKIN REMEDY 2 OZ",
      "code_information": [
        {
          "code": "3536085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 78.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-SKIN NO STING    MSC1528",
      "code_information": [
        {
          "code": "3536099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 142,
          "minimum": 48.5448,
          "maximum": 103.0494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.8054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-EYE FOAM       28300",
      "code_information": [
        {
          "code": "3536100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 957.0481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-JP 100ML  SU130-1305",
      "code_information": [
        {
          "code": "3538200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3539345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 197.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INITIATION BREAST MILK 673",
      "code_information": [
        {
          "code": "3539346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 356,
          "minimum": 111.22,
          "maximum": 258.3492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 237.6813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-BIS QUATTRO    186-0106",
      "code_information": [
        {
          "code": "3541300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 336,
          "minimum": 114.8666,
          "maximum": 243.8352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 224.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS PED DISP",
      "code_information": [
        {
          "code": "3541324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.8084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS ADLT DISP",
      "code_information": [
        {
          "code": "3541325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.8084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SKIN HNICU38",
      "code_information": [
        {
          "code": "3541328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 187.4057,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.0528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RECIP PLATELET     4C-2100",
      "code_information": [
        {
          "code": "3541430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 116.112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD FILTRATION   4020005",
      "code_information": [
        {
          "code": "3541446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 140.1372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.8113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BURETROL 150ML",
      "code_information": [
        {
          "code": "3541503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 252,
          "minimum": 86.1499,
          "maximum": 2947.8861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 168.2463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW RADIAL ARTERY",
      "code_information": [
        {
          "code": "3541912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.1613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP Y FOR BLOOD IV  D-100",
      "code_information": [
        {
          "code": "3541945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 162.3812,
          "maximum": 618.2964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 568.8327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DIALYZER EXELTRA    5M2119",
      "code_information": [
        {
          "code": "3541947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 292,
          "minimum": 99.8245,
          "maximum": 855.8379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 194.952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3541950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1539,
          "minimum": 365.3577,
          "maximum": 1116.8523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1027.5041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FEMORAL ART  C-PMS-401J-FA",
      "code_information": [
        {
          "code": "3542127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 828.0329,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO ALL SZ W/ STABILIZER",
      "code_information": [
        {
          "code": "3542128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1489,
          "minimum": 509.0368,
          "maximum": 1250.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 994.1219,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER HF 1000 PRISMAFLEX",
      "code_information": [
        {
          "code": "3542131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2248,
          "minimum": 99.5419,
          "maximum": 1631.3736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1500.8637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 110 INFUSION 1635101",
      "code_information": [
        {
          "code": "3542760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 1262.9031,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.7937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRISMAFLEX TPE2000 114093",
      "code_information": [
        {
          "code": "3542806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2271,
          "minimum": 99.5419,
          "maximum": 1648.0647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1516.2195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RADIAL ARTERY C-PMS-301-RA",
      "code_information": [
        {
          "code": "3543008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 61.171,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORACENTESIS      4653-48",
      "code_information": [
        {
          "code": "3543530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.4408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TUR IRRIGATION  06543-01",
      "code_information": [
        {
          "code": "3543551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 596.6953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE REPOSITION",
      "code_information": [
        {
          "code": "3543681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 497,
          "minimum": 169.9068,
          "maximum": 440.4312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 331.8191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE XL REPOSITION",
      "code_information": [
        {
          "code": "3543685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 38.3709,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 528.774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE SM   2042-01",
      "code_information": [
        {
          "code": "3543730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 126.7908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE LRG  2042-03",
      "code_information": [
        {
          "code": "3543732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 63.9515,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-NIPPLE REGULAR   67203S",
      "code_information": [
        {
          "code": "3544003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 92.3126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SEQ COMP KNEE      95xx",
      "code_information": [
        {
          "code": "3544619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 150.9456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.87,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501B",
      "code_information": [
        {
          "code": "3544638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.5347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501L",
      "code_information": [
        {
          "code": "3544639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 121.1919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 111.4965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE   VP501M",
      "code_information": [
        {
          "code": "3544640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 114.5566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.8113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530M",
      "code_information": [
        {
          "code": "3544645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.5347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530L",
      "code_information": [
        {
          "code": "3544650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 31.6977,
          "maximum": 164.0082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM CHILD        8001-01",
      "code_information": [
        {
          "code": "3544659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 41.3649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ELEVATOR     8011-02",
      "code_information": [
        {
          "code": "3544860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.1642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE ALL SZS TX4442-0x",
      "code_information": [
        {
          "code": "3545160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 92.8896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE PED       9007-00",
      "code_information": [
        {
          "code": "3545177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 299.7379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.1378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 3L   5B9858",
      "code_information": [
        {
          "code": "3545500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 539,
          "minimum": 184.2652,
          "maximum": 391.1523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 359.8601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 3L  5B9859",
      "code_information": [
        {
          "code": "3545502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 557,
          "minimum": 190.4187,
          "maximum": 404.2149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 371.8777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 2L  5B9896",
      "code_information": [
        {
          "code": "3545504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 501,
          "minimum": 171.2743,
          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 334.4896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 2L   5B9876",
      "code_information": [
        {
          "code": "3545505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.1016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIAL 1.5% 3L       5B9857",
      "code_information": [
        {
          "code": "3545515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 529,
          "minimum": 32.2538,
          "maximum": 383.8953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 353.1837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 1000ML  07139-09",
      "code_information": [
        {
          "code": "3545555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 2000ML  07973-07",
      "code_information": [
        {
          "code": "3545613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 73.8428,
          "maximum": 156.7512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 144.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-GYLCINE 1.5% IRRIG 3000ML",
      "code_information": [
        {
          "code": "3545747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 137.5347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML  07972-08",
      "code_information": [
        {
          "code": "3545751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 71.4498,
          "maximum": 151.6713,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 139.5376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 3000ML 07828-08",
      "code_information": [
        {
          "code": "3545752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 35.5904,
          "maximum": 151.6713,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 139.5376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML R5200-01",
      "code_information": [
        {
          "code": "3545753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 50.049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 1000ML 07953-09",
      "code_information": [
        {
          "code": "3545755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.0294,
          "maximum": 65.313,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 500ML R5201-01",
      "code_information": [
        {
          "code": "3545852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 39.1878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.0528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-MDI ADAPTER INLINE",
      "code_information": [
        {
          "code": "3545901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.0MM 2883-02-040",
      "code_information": [
        {
          "code": "3547925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3389.6286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-BENDING 03.501.072",
      "code_information": [
        {
          "code": "3547929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1032,
          "minimum": 352.8045,
          "maximum": 4743.533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 689.0086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 650.010",
      "code_information": [
        {
          "code": "3547941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM 60XL",
      "code_information": [
        {
          "code": "3547946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 231.1006,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 451.3273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIXER-CEMENT 3CC 658.969S",
      "code_information": [
        {
          "code": "3547948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.601S",
      "code_information": [
        {
          "code": "3547949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2016.2849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ULTRA ACCESS 658.902S",
      "code_information": [
        {
          "code": "3547952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5359,
          "minimum": 696.7933,
          "maximum": 3889.0263,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3577.9042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC M6275009/10",
      "code_information": [
        {
          "code": "3547958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 81.4526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-QUILL 2-0 YA-2034Q",
      "code_information": [
        {
          "code": "3547961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 336,
          "minimum": 114.8666,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 224.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-4-0 PROLENE 8526H",
      "code_information": [
        {
          "code": "3547969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 375.9236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT",
      "code_information": [
        {
          "code": "3547970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 221.3278,
          "maximum": 490.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 451.3273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX",
      "code_information": [
        {
          "code": "3547971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 398,
          "minimum": 136.0622,
          "maximum": 320.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 265.7223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY UNCUFF",
      "code_information": [
        {
          "code": "3547972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 384.5629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 2MM AR-7523",
      "code_information": [
        {
          "code": "3547986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-ZONE NAVIGATOR AR-7900",
      "code_information": [
        {
          "code": "3547987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 207.4253,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 650.112",
      "code_information": [
        {
          "code": "3547990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2992.9302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX CN",
      "code_information": [
        {
          "code": "3547997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 354.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 325.8103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX UN",
      "code_information": [
        {
          "code": "3547998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 402,
          "minimum": 31.1416,
          "maximum": 291.7314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 268.3929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SHILEY",
      "code_information": [
        {
          "code": "3547999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 373.1431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY CUFFED",
      "code_information": [
        {
          "code": "3548000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 671,
          "minimum": 229.3913,
          "maximum": 486.9447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 447.9891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED  4LPC",
      "code_information": [
        {
          "code": "3548001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 626,
          "minimum": 67.2881,
          "maximum": 454.2882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 417.9451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ4 S",
      "code_information": [
        {
          "code": "3548003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 121,
          "minimum": 37.2587,
          "maximum": 87.8097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-TRACH 15MM DECANN WHITE",
      "code_information": [
        {
          "code": "3548004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-TRACH SZ 1 DECANN SH",
      "code_information": [
        {
          "code": "3548005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 433.758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED",
      "code_information": [
        {
          "code": "3548006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 780,
          "minimum": 31.1416,
          "maximum": 566.046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 520.7623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY FLEX INNER",
      "code_information": [
        {
          "code": "3548007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 67.2881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FLUENT DISP FLT-112",
      "code_information": [
        {
          "code": "3548028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1739,
          "minimum": 594.503,
          "maximum": 1638.8267,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1161.0329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRESSING CHANGE 76681",
      "code_information": [
        {
          "code": "3549001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 275,
          "minimum": 94.0128,
          "maximum": 279.1622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 183.6021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEELIFT-AFO  081531532",
      "code_information": [
        {
          "code": "3549018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 842,
          "minimum": 287.8502,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 562.1562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-SUCTION NEURO NST031/25",
      "code_information": [
        {
          "code": "3549020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-SHANK MOD 5",
      "code_information": [
        {
          "code": "3549027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2016.2849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-LORDOTIC 5",
      "code_information": [
        {
          "code": "3549030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 15838.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1568.2958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KVLAB3C",
      "code_information": [
        {
          "code": "3549037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 116.8377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPEN 279726500",
      "code_information": [
        {
          "code": "3549047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3029,
          "minimum": 1035.5087,
          "maximum": 2198.1453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2022.2937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX ER VALVE REPLACEMEN",
      "code_information": [
        {
          "code": "3549059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 180.7325,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 374.5483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX CATH ACCESS 50-7280",
      "code_information": [
        {
          "code": "3549060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.9843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-NAVIGATION 286750210S",
      "code_information": [
        {
          "code": "3549063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1792.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 020 XFR004xxx",
      "code_information": [
        {
          "code": "3549066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2903,
          "minimum": 992.4337,
          "maximum": 2273.3368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1938.1705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL SND1T3 20.5",
      "code_information": [
        {
          "code": "3549069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5049,
          "minimum": 1726.0757,
          "maximum": 3664.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3370.9346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-SYNC DISTAL RADIAL, SDRB-",
      "code_information": [
        {
          "code": "3549082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 271.0635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-FEMORAL AUG SZ6 154906002",
      "code_information": [
        {
          "code": "3549097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- LIGHT 03.612.021S",
      "code_information": [
        {
          "code": "3549135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2191,
          "minimum": 749.0259,
          "maximum": 1590.0087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1462.808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LIGHT 03.615.132S",
      "code_information": [
        {
          "code": "3549136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1748,
          "minimum": 597.5798,
          "maximum": 1268.5236,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1167.0417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 388.175",
      "code_information": [
        {
          "code": "3549150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1078,
          "minimum": 368.5303,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 719.7202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 9-0 V449G",
      "code_information": [
        {
          "code": "3549155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.8817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHALANGEAL 20MM",
      "code_information": [
        {
          "code": "3549160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2016.2849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADER-TRIAL DRG 7032ANS",
      "code_information": [
        {
          "code": "3549166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1792.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL PRP ABS-10061T",
      "code_information": [
        {
          "code": "3549185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1456.1316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.021S",
      "code_information": [
        {
          "code": "3549190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2362,
          "minimum": 807.4848,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1576.9751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703713",
      "code_information": [
        {
          "code": "3549201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1129.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TAP 12.5MM 338.17",
      "code_information": [
        {
          "code": "3549204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1784.6124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- CANN 6.5MM 702603",
      "code_information": [
        {
          "code": "3549216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2032,
          "minimum": 580.0123,
          "maximum": 1474.6224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1356.6526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CSG WORLEY STANDARD",
      "code_information": [
        {
          "code": "3549218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1900,
          "minimum": 649.5432,
          "maximum": 1378.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1268.5236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-UNCUFFED 7.0 70XLTUP",
      "code_information": [
        {
          "code": "3549227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 231.1006,
          "maximum": 1146.6782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 451.3273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.1X87 A-3836",
      "code_information": [
        {
          "code": "3549229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CROSS PLATE 705172",
      "code_information": [
        {
          "code": "3549243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2762,
          "minimum": 944.2307,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1844.0327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL CPRP ABS-10063",
      "code_information": [
        {
          "code": "3549250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1980,
          "minimum": 676.8924,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1321.9351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-THREAD LOCK 03.835.009S",
      "code_information": [
        {
          "code": "3549252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1698,
          "minimum": 491.0363,
          "maximum": 1232.2386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1133.6595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPEEDGUIDE-T8 2.4/2.7X30MM",
      "code_information": [
        {
          "code": "3549269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2408,
          "minimum": 823.2106,
          "maximum": 3101.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1607.6868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEEDGUIDE AO 2.0X30MM",
      "code_information": [
        {
          "code": "3549270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5577,
          "minimum": 249.1328,
          "maximum": 4047.2289,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3723.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 2.1MM",
      "code_information": [
        {
          "code": "3549272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1742,
          "minimum": 595.5286,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1163.0358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS TRIPLE 91429",
      "code_information": [
        {
          "code": "3549278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 453,
          "minimum": 154.8648,
          "maximum": 1347.4303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 302.4427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.1X300MM RMT3130",
      "code_information": [
        {
          "code": "3549279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2423,
          "minimum": 575.0074,
          "maximum": 1758.3711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1617.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-2.5 SOLID HT-2502",
      "code_information": [
        {
          "code": "3549283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 71.1808,
          "maximum": 1091.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1004.1366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-DHS REAMER 338.13",
      "code_information": [
        {
          "code": "3549287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7319,
          "minimum": 1455.3137,
          "maximum": 5311.3983,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4886.4864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-PALM ROLYAN SOFT GEL LT",
      "code_information": [
        {
          "code": "3549295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 246,
          "minimum": 84.0988,
          "maximum": 178.5222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 164.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FORCEP SUCTION 9G12R",
      "code_information": [
        {
          "code": "3549304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 6512.4871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CATH LINE 020378801",
      "code_information": [
        {
          "code": "3549311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 3739.2164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM 6149.1035",
      "code_information": [
        {
          "code": "3549338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 265.8158,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 650.114",
      "code_information": [
        {
          "code": "3549348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ANGLE 14MM 684.434",
      "code_information": [
        {
          "code": "3549349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2016.2849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 16MM 650.116",
      "code_information": [
        {
          "code": "3549372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP 2.4MM",
      "code_information": [
        {
          "code": "3549451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 219.6549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB LARGE AR-8970-09",
      "code_information": [
        {
          "code": "3549452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 941.378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ADAPTER BIOPSY MAJ-1414",
      "code_information": [
        {
          "code": "3549507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 35676.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.4555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-THUMB SPICA ANY    350S",
      "code_information": [
        {
          "code": "3549700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 578.9001,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.7937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUICKCLOT 8X8 4010",
      "code_information": [
        {
          "code": "3549703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 695.0174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-COMFY FINGER",
      "code_information": [
        {
          "code": "3549716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 405.3969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.0997,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 6 6SIC",
      "code_information": [
        {
          "code": "3549725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 89.2611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 8 8SIC",
      "code_information": [
        {
          "code": "3549726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 14374.0728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUIKCLOT 5X5 4000",
      "code_information": [
        {
          "code": "3549730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 733,
          "minimum": 250.5869,
          "maximum": 531.9381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 489.3831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOCN0346",
      "code_information": [
        {
          "code": "3549731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 261.5266,
          "maximum": 1829.0129,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 510.7477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 200 AC-10030100",
      "code_information": [
        {
          "code": "3549732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3289,
          "minimum": 7.7854,
          "maximum": 2386.8273,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2195.8811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ESOPHAGEAL 100001",
      "code_information": [
        {
          "code": "3549734",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 337.5527,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1769.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BV175-6 BLUE EPM8743",
      "code_information": [
        {
          "code": "3549735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 607,
          "minimum": 207.512,
          "maximum": 1436.9624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 405.2599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 365 AC-10030110",
      "code_information": [
        {
          "code": "3549736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1725.1921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LONG TUNNELING SC-4254",
      "code_information": [
        {
          "code": "3549742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 2490.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1344.635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM 03.010.061",
      "code_information": [
        {
          "code": "3549747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1751,
          "minimum": 598.6054,
          "maximum": 2885.6029,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1169.0446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 16MM 03.037.002",
      "code_information": [
        {
          "code": "3549748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5189,
          "minimum": 1773.9368,
          "maximum": 3765.6573,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3464.4047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 6-9MM 03.037.022",
      "code_information": [
        {
          "code": "3549750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3479,
          "minimum": 112.3322,
          "maximum": 2524.7103,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2322.7335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-BABYFLOW PLUS S DISP MP37",
      "code_information": [
        {
          "code": "3549751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.8641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-DISP",
      "code_information": [
        {
          "code": "3549752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 178,
          "minimum": 60.8519,
          "maximum": 129.1746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 118.8406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEOMASK-CPAP",
      "code_information": [
        {
          "code": "3549753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 142.2372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.8582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BABUFLOE SZ 4 DISP MP0149",
      "code_information": [
        {
          "code": "3549754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 225,
          "minimum": 76.9196,
          "maximum": 163.2825,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.2199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP",
      "code_information": [
        {
          "code": "3549755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.1759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PNEUMOTHORAX G05297",
      "code_information": [
        {
          "code": "3549757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1013,
          "minimum": 200.196,
          "maximum": 735.1341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 676.3234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOURNIQUET-TACTICAL 30-0023",
      "code_information": [
        {
          "code": "3549759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 360,
          "minimum": 123.0713,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 240.3518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R001",
      "code_information": [
        {
          "code": "3549765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 1875.2088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1725.1921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-A003",
      "code_information": [
        {
          "code": "3549766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 601.7002,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2128.4491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-SEATTLE PLUS MP02260",
      "code_information": [
        {
          "code": "3549776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 99.5419,
          "maximum": 409.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 376.5512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-DISTAL 24MM 03.211.024",
      "code_information": [
        {
          "code": "3549786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 902.5232,
          "maximum": 1915.848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1762.5802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PROX 24MM 03.211.124",
      "code_information": [
        {
          "code": "3549787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 902.5232,
          "maximum": 3736.4359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1762.5802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROCESSOR-SOUND LINE 90711",
      "code_information": [
        {
          "code": "3549810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 141.2494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-BAHA STORAGE Z342010",
      "code_information": [
        {
          "code": "3549811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 2902.2859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-PERFORM REV PERI MWJ126",
      "code_information": [
        {
          "code": "3549818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.6469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5X220MM DWD017",
      "code_information": [
        {
          "code": "3549819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 950,
          "minimum": 324.7716,
          "maximum": 3199.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 634.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SHAFT 8X510 0227-8510S",
      "code_information": [
        {
          "code": "3549851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1867,
          "minimum": 638.2617,
          "maximum": 2859.4662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1246.4913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LOCKING 705078",
      "code_information": [
        {
          "code": "3549854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1563,
          "minimum": 534.3348,
          "maximum": 1251.7811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1043.5276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 700354",
      "code_information": [
        {
          "code": "3549867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1228,
          "minimum": 419.81,
          "maximum": 891.1596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 819.8668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW INFINITY 3600315",
      "code_information": [
        {
          "code": "3549870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 2635.3579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 836.5579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.4 G3606010",
      "code_information": [
        {
          "code": "3549873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 2635.3579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-STRAIGH TIP 2762-01-0004",
      "code_information": [
        {
          "code": "3549916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 1078.5836,
          "maximum": 9858.5408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2106.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR NIM 945NSD2750",
      "code_information": [
        {
          "code": "3549918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 10600.3782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2217.9134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAGITTAL 2296-003-155",
      "code_information": [
        {
          "code": "3549927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 417.6311,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.0459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 2.4 1608-006-147",
      "code_information": [
        {
          "code": "3549928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 751,
          "minimum": 256.7405,
          "maximum": 545.0007,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 501.4006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 1MM 1608-006-151",
      "code_information": [
        {
          "code": "3549929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 722,
          "minimum": 207.4253,
          "maximum": 523.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-413S1",
      "code_information": [
        {
          "code": "3549931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 289.7281,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.0459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 7X15MM 2296-003-103",
      "code_information": [
        {
          "code": "3549932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 178.1116,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 347.8425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-111S5",
      "code_information": [
        {
          "code": "3549933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.0459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHORT 2.5MM 2296-003-413",
      "code_information": [
        {
          "code": "3549934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 501,
          "minimum": 125.6786,
          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 334.4896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48X70MM 2108-197-00S4",
      "code_information": [
        {
          "code": "3549935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 77.2615,
          "maximum": 409.8457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.8875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X75MM 4125-089-075",
      "code_information": [
        {
          "code": "3549936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 737,
          "minimum": 251.9544,
          "maximum": 534.8409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 492.0536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90 4125-097-090",
      "code_information": [
        {
          "code": "3549937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 434.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 399.9188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 13X90MM 4113-119-090",
      "code_information": [
        {
          "code": "3549938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 434.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 399.9188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-119-090",
      "code_information": [
        {
          "code": "3549939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 262.2103,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 512.0829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-127-090",
      "code_information": [
        {
          "code": "3549940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 262.2103,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 512.0829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-70X12.5MM 0277-096-277",
      "code_information": [
        {
          "code": "3549941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 572,
          "minimum": 195.5467,
          "maximum": 415.1004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 381.8924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RECIPR. 0277-096-325",
      "code_information": [
        {
          "code": "3549942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 583,
          "minimum": 199.3072,
          "maximum": 462.6752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 389.2365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 6125-119-090",
      "code_information": [
        {
          "code": "3549943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 832,
          "minimum": 284.4316,
          "maximum": 603.7824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 555.4798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-18.5X90.5 2108-382-003",
      "code_information": [
        {
          "code": "3549944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 618,
          "minimum": 211.2725,
          "maximum": 11930.0133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 412.604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE,SAW VASC 5400-134-415",
      "code_information": [
        {
          "code": "3549951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 685,
          "minimum": 234.1774,
          "maximum": 1138.3367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 457.3361,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE, SAW 25X90MM 6725-127-09",
      "code_information": [
        {
          "code": "3549952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2047,
          "minimum": 699.7974,
          "maximum": 2788.8415,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 8MM M0013635",
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        {
          "code": "3549961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 155.708,
          "maximum": 2995.6896,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2756.0344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SPINAL W/EPI & BUPIV 3338",
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        {
          "code": "3549962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 949.8188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 186.9403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-VISTASEAL VSTL35",
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        {
          "code": "3549965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 279.9873,
          "maximum": 31619.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SUTURE UCL AR-7715-4.5",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1340.4521,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-SPIN ACCESS INS-5900",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 774.0912,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-75MM 00-5901-020-00",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 849.5342,
          "maximum": 11710.9099,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-TIB 42-5320-064-02",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 3177.9757,
          "maximum": 11905.5449,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-REVERSED GLEN MWJ004",
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          "code": "3550025",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 688.5158,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1344.635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-PRESS FIT REV DWJ002",
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        {
          "code": "3550026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 207.4253,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DSIP RFID EXPIRATORY MP0",
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        {
          "code": "3550040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 108.713,
          "maximum": 721.8178,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 212.3108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC D-BLADE",
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        {
          "code": "3550048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 106.32,
          "maximum": 225.6927,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 207.6373,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #3 MILLER",
      "code_information": [
        {
          "code": "3550049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 82.7313,
          "maximum": 579.4562,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 161.5698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WALKER-CAM  II 55988503",
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        {
          "code": "3550050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 356.2232,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 695.685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-2.5X7MM AR-8998DS",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1388.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 PC-5",
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        {
          "code": "3550066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 22.2212,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 18\\\" PC-3",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 22.9049,
          "maximum": 5332.999,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROS-NASAL SEPTAL ROUND SP1102",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 631.0825,
          "maximum": 2494.1085,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.007.01S",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 704.2416,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP LRG 47800100",
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        {
          "code": "3550087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 665.6109,
          "maximum": 1412.9379,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP REG 47700100",
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        {
          "code": "3550088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 585.2726,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP SLIM 4760010",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 62.8393,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CAN 190MM 03.010.036",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 50.049,
          "maximum": 2447.7861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 6MMX10CM M00",
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        {
          "code": "3550094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2529,
          "minimum": 864.5762,
          "maximum": 14053.2031,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-ANNULOTOMY 675.405S",
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        {
          "code": "3550111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 917.9071,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-SHIM SS 6133.0326S",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.914S",
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        {
          "code": "3550136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 551.6512,
          "maximum": 3684.3789,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CT 3.5M 6149.9135",
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        {
          "code": "3550137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 339.1299,
          "maximum": 3153.6431,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 662.3028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIABETIC FOOT CARE 0811748",
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        {
          "code": "3550156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 159.654,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 146.8817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 71MM 705506",
      "code_information": [
        {
          "code": "3550158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1223,
          "minimum": 331.9917,
          "maximum": 887.5311,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 816.5286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT RSZ4001S",
      "code_information": [
        {
          "code": "3550168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1980,
          "minimum": 676.8924,
          "maximum": 2744.9096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1321.9351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW 1020-00-000",
      "code_information": [
        {
          "code": "3550179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 780.2083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-C001",
      "code_information": [
        {
          "code": "3550198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 941.378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22GX9CM",
      "code_information": [
        {
          "code": "3550200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 10649.315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 271.0635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.8X122 A-3738",
      "code_information": [
        {
          "code": "3550221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIMED RX COUDE 1314ANS",
      "code_information": [
        {
          "code": "3550227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 12179.7022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CERV MOBI-C 13X17 MB3375",
      "code_information": [
        {
          "code": "3550228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21902,
          "minimum": 1119.9854,
          "maximum": 15894.2814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14622.7389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPAR 14MM 0024-LDR",
      "code_information": [
        {
          "code": "3550229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 12179.7022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1344.635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYGEN VOCSN PRT-00930",
      "code_information": [
        {
          "code": "3550231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 393,
          "minimum": 134.3529,
          "maximum": 3864.895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.3841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE 2.5MM 694",
      "code_information": [
        {
          "code": "3550236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5953,
          "minimum": 2035.1215,
          "maximum": 4320.0921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3974.4847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-INSERTER",
      "code_information": [
        {
          "code": "3550237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1866.2716,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-T 601.800",
      "code_information": [
        {
          "code": "3550239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3487,
          "minimum": 933.1358,
          "maximum": 2530.5159,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2328.0746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPANNER-WRENCH 687.509",
      "code_information": [
        {
          "code": "3550240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INSERTER 694.004",
      "code_information": [
        {
          "code": "3550241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4175,
          "minimum": 1427.2858,
          "maximum": 3029.7975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2787.4137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-INSERTER 694.005",
      "code_information": [
        {
          "code": "3550242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 3070.4367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2824.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-CALIBER GRAPHIC 994.001",
      "code_information": [
        {
          "code": "3550244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14166,
          "minimum": 4842.8576,
          "maximum": 22391.3665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9457.8449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARGYLE SHUNT 8888577775",
      "code_information": [
        {
          "code": "3550249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 142.5576,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 278.4075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND A31216",
      "code_information": [
        {
          "code": "3550250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 93.4248,
          "maximum": 361.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 332.4867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-MEPITEL 6.8X10",
      "code_information": [
        {
          "code": "3550253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 186.8496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 127.52,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 12FR 1.0CM",
      "code_information": [
        {
          "code": "3550256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 3921.0611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 641.6059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-I/A CAPSULGUARD",
      "code_information": [
        {
          "code": "3550264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.2609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE RT SM 70831",
      "code_information": [
        {
          "code": "3550272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 338,
          "minimum": 115.5503,
          "maximum": 245.2866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 225.6637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE LT SM 70831",
      "code_information": [
        {
          "code": "3550273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 121.0202,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 236.346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-OSTEOFUZE OF-BMA-11",
      "code_information": [
        {
          "code": "3550274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8800,
          "minimum": 483.807,
          "maximum": 6386.16,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5875.2672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET REUSE",
      "code_information": [
        {
          "code": "3550275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 870,
          "minimum": 80.6345,
          "maximum": 631.359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 580.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-HEMOSTATIC POWDER 1978",
      "code_information": [
        {
          "code": "3550278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 10602.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 494.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R002",
      "code_information": [
        {
          "code": "3550306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1725.1921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TROCAR THORACIC 24FR SWD",
      "code_information": [
        {
          "code": "3550314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 110.7642,
          "maximum": 477.6899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.3167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-INSPIRA BREAST SRM",
      "code_information": [
        {
          "code": "3550331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4485,
          "minimum": 232.4498,
          "maximum": 3254.7645,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2994.3833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DEFENDO Y-OPSY 100303",
      "code_information": [
        {
          "code": "3550394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 640.0711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.4203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PUSHLOCK 2.9MM",
      "code_information": [
        {
          "code": "3550395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1151,
          "minimum": 393.4865,
          "maximum": 835.2807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 768.4582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM",
      "code_information": [
        {
          "code": "3550396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 906.6606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH 8MM 100/897/080",
      "code_information": [
        {
          "code": "3550399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 878,
          "minimum": 75.6296,
          "maximum": 637.1646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 586.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER 8MM 100/890/080",
      "code_information": [
        {
          "code": "3550400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 18FR 897518",
      "code_information": [
        {
          "code": "3550406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 195,
          "minimum": 66.6636,
          "maximum": 141.5115,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.1906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-TRIPLE NEEDLE INS-5300",
      "code_information": [
        {
          "code": "3550411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4172,
          "minimum": 1426.2602,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2785.4108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPIN W/ADAPTER INS-5910",
      "code_information": [
        {
          "code": "3550414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4906,
          "minimum": 207.4253,
          "maximum": 3560.2842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3275.4615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J556G",
      "code_information": [
        {
          "code": "3550419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 132.8031,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.1789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0 770G",
      "code_information": [
        {
          "code": "3550420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 52.8295,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 133.5288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8695G",
      "code_information": [
        {
          "code": "3550421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 6549.7458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-REDDIE KNEE XL 08154723",
      "code_information": [
        {
          "code": "3550426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 437,
          "minimum": 148.4787,
          "maximum": 317.1309,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 291.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-BACK ROLYANFIT MESH",
      "code_information": [
        {
          "code": "3550427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 46414.3304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.2609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-2.3MM PED SCREW 4008-00",
      "code_information": [
        {
          "code": "3550429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 811.906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.4055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING RS5200",
      "code_information": [
        {
          "code": "3550447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5472,
          "minimum": 325.3185,
          "maximum": 3971.0304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3653.348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-FIXATION LG FP9000L",
      "code_information": [
        {
          "code": "3550448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 36889.4496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 390.5717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-PRIME 286750200S",
      "code_information": [
        {
          "code": "3550473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 9520.9881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1792.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-MMG 2862-02-108",
      "code_information": [
        {
          "code": "3550480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1175,
          "minimum": 401.6912,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 784.4817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 03.010.060",
      "code_information": [
        {
          "code": "3550483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1814,
          "minimum": 620.1429,
          "maximum": 7248.7635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1211.1062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-120",
      "code_information": [
        {
          "code": "3550487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 344.2579,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 672.3175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-120LP",
      "code_information": [
        {
          "code": "3550488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 959,
          "minimum": 327.8484,
          "maximum": 721.8178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 640.2706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MACY BEDSIDE DELIVERY M",
      "code_information": [
        {
          "code": "3550498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 932,
          "minimum": 88.4199,
          "maximum": 676.3524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 622.2442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PRESSURE OPAQUE 50P148",
      "code_information": [
        {
          "code": "3550499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 369.8065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH,MALE EXTERNAL",
      "code_information": [
        {
          "code": "3550511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH PEDIATRIC",
      "code_information": [
        {
          "code": "3550515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO CF DEL FGS-0635",
      "code_information": [
        {
          "code": "3550530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2212,
          "minimum": 756.2051,
          "maximum": 7374.4421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1476.8285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM ST 6149.1036S",
      "code_information": [
        {
          "code": "3550541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 662.3028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF MED MDS601MD",
      "code_information": [
        {
          "code": "3550553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 105.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF XL MDS601BD",
      "code_information": [
        {
          "code": "3550555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.5317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT MED MDS620",
      "code_information": [
        {
          "code": "3550556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 257,
          "minimum": 87.8593,
          "maximum": 186.5049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 171.5845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT LRG MDS620L",
      "code_information": [
        {
          "code": "3550557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 277,
          "minimum": 94.6966,
          "maximum": 201.0189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.9374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH MED MDS630MD",
      "code_information": [
        {
          "code": "3550558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 351,
          "minimum": 119.9946,
          "maximum": 254.7207,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 234.343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH LRG MDS630LD",
      "code_information": [
        {
          "code": "3550559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH X-LG MDS630BD",
      "code_information": [
        {
          "code": "3550560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 383,
          "minimum": 130.9342,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.7077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT 10° TIP MLD-0068",
      "code_information": [
        {
          "code": "3550592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 662.3151,
          "maximum": 2289.5835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2106.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.5X350MM PK6 MLD-0301",
      "code_information": [
        {
          "code": "3550593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 2744.9096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 795.164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-8/13/18MM MLD-0441S",
      "code_information": [
        {
          "code": "3550594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1041.5753,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3295.4908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIM-SPIKE BLUNT MLD-0513",
      "code_information": [
        {
          "code": "3550595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1873,
          "minimum": 640.3129,
          "maximum": 1359.2361,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1250.4972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- DILATOR MLD-0345",
      "code_information": [
        {
          "code": "3550596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 9520.9881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 795.164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-THORACIC TGMR312610",
      "code_information": [
        {
          "code": "3550613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84847,
          "minimum": 3513.4398,
          "maximum": 61573.4679,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56647.5905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X12MM 03.501.762",
      "code_information": [
        {
          "code": "3550619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2487,
          "minimum": 207.4253,
          "maximum": 1804.8159,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1660.4306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX16CM",
      "code_information": [
        {
          "code": "3550630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 382.56,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX16CM",
      "code_information": [
        {
          "code": "3550631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICAL SCREW 3603-00-TE",
      "code_information": [
        {
          "code": "3550634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.4055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PEDIATRIC YG-232T",
      "code_information": [
        {
          "code": "3550638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.6285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC 153509",
      "code_information": [
        {
          "code": "3550645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3ML 165810",
      "code_information": [
        {
          "code": "3550646",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 37.3881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-MARKING ROBOTIP INFARED",
      "code_information": [
        {
          "code": "3550649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 473.2411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE F/MRI SQK65VS",
      "code_information": [
        {
          "code": "3550657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 164.7339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 151.5552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE,FLEX FLEX-200-QFT",
      "code_information": [
        {
          "code": "3550658",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 769.6424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.8084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE 24F 5CC 0",
      "code_information": [
        {
          "code": "3550665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 170,
          "minimum": 58.117,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 113.4995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ASSEMBLY DISP 83030-1",
      "code_information": [
        {
          "code": "3550668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1576,
          "minimum": 538.779,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1052.2069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY 18G ANG 221251",
      "code_information": [
        {
          "code": "3550683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 149,
          "minimum": 50.9379,
          "maximum": 438.2068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 99.479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VS-1 5FR 80CM BEACON TIP",
      "code_information": [
        {
          "code": "3550691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 229.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-VASC 14X7MM SBT1402D",
      "code_information": [
        {
          "code": "3550693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 346.4503,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL DETACHMENT RH1",
      "code_information": [
        {
          "code": "3550699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1066.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE D9212",
      "code_information": [
        {
          "code": "3550703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1077,
          "minimum": 368.1885,
          "maximum": 4252.4967,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 719.0526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SMARTRELEASE ONYX 83030-",
      "code_information": [
        {
          "code": "3550710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1969,
          "minimum": 497.7095,
          "maximum": 1428.9033,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1314.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM 2.3MM 2862-02-201",
      "code_information": [
        {
          "code": "3550713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3171,
          "minimum": 1084.0535,
          "maximum": 7919.9762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2117.0991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE ULTRASOUND 8’ CVC6",
      "code_information": [
        {
          "code": "3550720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BONE HARVEST 03.404.000S",
      "code_information": [
        {
          "code": "3550737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12726,
          "minimum": 870.8526,
          "maximum": 9235.2582,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8496.4375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MENISCAL ROOT 71935068",
      "code_information": [
        {
          "code": "3550740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5252,
          "minimum": 1795.4742,
          "maximum": 3811.3764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3506.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-REAMER",
      "code_information": [
        {
          "code": "3550752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3893,
          "minimum": 60.6149,
          "maximum": 2825.1501,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2599.1381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXY ADULT ETCO2 OM-2125-8",
      "code_information": [
        {
          "code": "3550753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONET 188MM 1563-00",
      "code_information": [
        {
          "code": "3550760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 4252.4967,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1344.635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT INTERSTIM 3560022",
      "code_information": [
        {
          "code": "3550762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1631,
          "minimum": 557.5816,
          "maximum": 1183.6167,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1088.9274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 3MM BIT DK-300",
      "code_information": [
        {
          "code": "3550765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2326,
          "minimum": 795.1777,
          "maximum": 4216.3502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1552.9399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DECOMPRESSION ZZ-0056",
      "code_information": [
        {
          "code": "3550777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.1701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,LASER TRACH",
      "code_information": [
        {
          "code": "3550778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 675.725S",
      "code_information": [
        {
          "code": "3550783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8123,
          "minimum": 2776.9683,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5423.2722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP THR 1.35M",
      "code_information": [
        {
          "code": "3550793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 48.3807,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0 8762H",
      "code_information": [
        {
          "code": "3550794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (15) 8800966",
      "code_information": [
        {
          "code": "3550803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 187.4057,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (5) 8801002",
      "code_information": [
        {
          "code": "3550804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 337,
          "minimum": 115.2085,
          "maximum": 884.7551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 224.996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 4.6X220 P99-110-4622",
      "code_information": [
        {
          "code": "3550805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1591,
          "minimum": 543.907,
          "maximum": 10633.7442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1062.2216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM ADJ 2862-02-200",
      "code_information": [
        {
          "code": "3550815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3171,
          "minimum": 818.5792,
          "maximum": 2301.1947,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2117.0991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.1X50 M-R 01-7141",
      "code_information": [
        {
          "code": "3550816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1472,
          "minimum": 503.2251,
          "maximum": 4615.0739,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 982.772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL EMBOLIZATION PODH1",
      "code_information": [
        {
          "code": "3550822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 15669.2297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1066.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 AO A-8004.03",
      "code_information": [
        {
          "code": "3550830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1879,
          "minimum": 642.3641,
          "maximum": 4742.9769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1254.5031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 16FR PEDS 8016",
      "code_information": [
        {
          "code": "3550842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 2791.622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.45MM SM 45303145",
      "code_information": [
        {
          "code": "3550850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 207.4253,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAGE-12MM/8° 50/18 LUI81249",
      "code_information": [
        {
          "code": "3550854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 19856,
          "minimum": 870.8526,
          "maximum": 14409.4992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 13256.7393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-CUSTOM MED PK623984",
      "code_information": [
        {
          "code": "3550856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52648,
          "minimum": 667.8761,
          "maximum": 38206.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 35150.1213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BAL RX DC-RYxxxxxx",
      "code_information": [
        {
          "code": "3550857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 2455.1815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-R2P MISAGO SXRxxxxxx",
      "code_information": [
        {
          "code": "3550858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4415,
          "minimum": 1028.785,
          "maximum": 3203.9655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2947.6483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-METACROSS BD-xxxxxxxx",
      "code_information": [
        {
          "code": "3550859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1850,
          "minimum": 632.45,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1235.1414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT F/2.16MM 3560030",
      "code_information": [
        {
          "code": "3550864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 14240.6088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-INTERPULSE",
      "code_information": [
        {
          "code": "3550869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-SKULL MOUNT 9735300",
      "code_information": [
        {
          "code": "3550873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1643,
          "minimum": 561.684,
          "maximum": 1192.3251,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1096.9391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PERFORATED FUNCTIONAL 0",
      "code_information": [
        {
          "code": "3550898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 192.2815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-HI-SPEED 4X11 1884068HS",
      "code_information": [
        {
          "code": "3550911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2381,
          "minimum": 813.9802,
          "maximum": 1727.8917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1589.6604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PROLAPSE HEM3335",
      "code_information": [
        {
          "code": "3550912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2317,
          "minimum": 792.1009,
          "maximum": 3664.1429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1546.9311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM XT SIGTRSB60AXT",
      "code_information": [
        {
          "code": "3550915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3076,
          "minimum": 1051.5763,
          "maximum": 2232.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2053.6729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM MT SIGTRSB60AMT",
      "code_information": [
        {
          "code": "3550916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 865.2916,
          "maximum": 1851.2607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1703.1598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3551250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 38.3709,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.4936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PRECISE SKIN      DS-5",
      "code_information": [
        {
          "code": "3552655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 68.4003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT  STR 35R",
      "code_information": [
        {
          "code": "3552730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 36.1465,
          "maximum": 89.2611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3552731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3552732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXW35",
      "code_information": [
        {
          "code": "3552737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 333.1039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.4672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKING-COMPRESSION CUSTOM",
      "code_information": [
        {
          "code": "3553701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 5096.1004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 399.9188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-BONE",
      "code_information": [
        {
          "code": "3554025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9164,
          "minimum": 74.5174,
          "maximum": 6650.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6118.2896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CLAVICAL ADULT ALL 3001s",
      "code_information": [
        {
          "code": "3554085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 192.9667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "3554974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 231.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3554981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 142.5576,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 278.4075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-1/2\\\"X2\\\" SMALL    1955",
      "code_information": [
        {
          "code": "3555059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 440.4312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 232.3401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2\\\"X14\\\" LARGE     1951",
      "code_information": [
        {
          "code": "3555109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 270.757,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 528.774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2 X 3 MEDIUM     1953",
      "code_information": [
        {
          "code": "3555158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 489,
          "minimum": 65.0637,
          "maximum": 354.8673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 326.4779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP MED  202549",
      "code_information": [
        {
          "code": "3555307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 84.9069,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP LG   202636",
      "code_information": [
        {
          "code": "3555315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 274.1573,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORIE-XLGE 202612&201352",
      "code_information": [
        {
          "code": "3555323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 493,
          "minimum": 33.366,
          "maximum": 357.7701,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 329.1485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       G121H",
      "code_information": [
        {
          "code": "3555374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0 FS-2   636H",
      "code_information": [
        {
          "code": "3555390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 23.9123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.6764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-DEXON           7618-41",
      "code_information": [
        {
          "code": "3556875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 43,
          "minimum": 14.7002,
          "maximum": 31.2051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 28.7087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0   1663H",
      "code_information": [
        {
          "code": "3557098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 41,
          "minimum": 7.7854,
          "maximum": 29.7537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 27.3734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3557628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 36.1465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.6764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 6-0 P1       697G",
      "code_information": [
        {
          "code": "3557898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        698H",
      "code_information": [
        {
          "code": "3557956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        990H",
      "code_information": [
        {
          "code": "3558678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 8.8976,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685G",
      "code_information": [
        {
          "code": "3558679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 16,
          "minimum": 5.4698,
          "maximum": 51.7173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 10.6823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1653-G",
      "code_information": [
        {
          "code": "3558947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 27.2489,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1663-H",
      "code_information": [
        {
          "code": "3558970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 49,
          "minimum": 16.7514,
          "maximum": 40.5953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 32.7146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0       1667G",
      "code_information": [
        {
          "code": "3558978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 3-0       1669H",
      "code_information": [
        {
          "code": "3558982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 220.7717,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE P99-930-2108",
      "code_information": [
        {
          "code": "3559011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3368,
          "minimum": 900.3259,
          "maximum": 2444.1576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2248.625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       G695G",
      "code_information": [
        {
          "code": "3559030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1696-G",
      "code_information": [
        {
          "code": "3559036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.0821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON           1698G",
      "code_information": [
        {
          "code": "3559069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM MT SIGTRSB45AMT",
      "code_information": [
        {
          "code": "3559071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2310,
          "minimum": 789.7078,
          "maximum": 2108.1751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1542.2576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-LONG 4.2MM 703545",
      "code_information": [
        {
          "code": "3559085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3448,
          "minimum": 870.8526,
          "maximum": 2502.2136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2302.0365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-5X100MM FIX UNVCA5STF",
      "code_information": [
        {
          "code": "3559095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 156,
          "minimum": 53.3309,
          "maximum": 247.4645,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 104.1525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 15MM ONB15STF",
      "code_information": [
        {
          "code": "3559096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.1016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 5MM ONB5STF",
      "code_information": [
        {
          "code": "3559097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 286,
          "minimum": 97.7733,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 190.9462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3559115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 21028.3654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 12FR 0200-12L",
      "code_information": [
        {
          "code": "3559117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 473.141,
          "maximum": 1004.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 924.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM CDH29P",
      "code_information": [
        {
          "code": "3559120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2660,
          "minimum": 497.7095,
          "maximum": 1930.362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1775.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3559142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2143,
          "minimum": 142.9177,
          "maximum": 1555.1751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1430.7611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15MM XTHICK SIG60AXT",
      "code_information": [
        {
          "code": "3559150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1896,
          "minimum": 648.1758,
          "maximum": 3212.5897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1265.853,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1065832",
      "code_information": [
        {
          "code": "3559158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 351.4552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.1378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIAMONDTOUCH IN9152",
      "code_information": [
        {
          "code": "3559159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 632,
          "minimum": 216.0586,
          "maximum": 1504.2505,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 421.951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN GUARD",
      "code_information": [
        {
          "code": "3559160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1805.977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLLEVE-SPIN GUARD",
      "code_information": [
        {
          "code": "3559161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1702,
          "minimum": 581.854,
          "maximum": 1235.1414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1136.3301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYDROGEL EEG",
      "code_information": [
        {
          "code": "3559175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J493H",
      "code_information": [
        {
          "code": "3559178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0 1635G",
      "code_information": [
        {
          "code": "3559179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 100.6541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J670G",
      "code_information": [
        {
          "code": "3559180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP497G",
      "code_information": [
        {
          "code": "3559181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 185,
          "minimum": 63.245,
          "maximum": 134.2545,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 123.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-12MM 10*/MD 08.815.242S",
      "code_information": [
        {
          "code": "3559197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 23165,
          "minimum": 1787.3054,
          "maximum": 16810.8405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 15465.9733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW-ACC BONCH AF541",
      "code_information": [
        {
          "code": "3559228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW,STD BLUE AF541 73-112096",
      "code_information": [
        {
          "code": "3559229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 10665.4419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM/MED/LG",
      "code_information": [
        {
          "code": "3559240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 189,
          "minimum": 64.6125,
          "maximum": 105398.1891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 126.1847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.2MM XS 45303125",
      "code_information": [
        {
          "code": "3559246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD 4033A",
      "code_information": [
        {
          "code": "3559253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X40MM 7005-3340",
      "code_information": [
        {
          "code": "3559254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 433.2429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X60MM 7005-3360",
      "code_information": [
        {
          "code": "3559255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 2859.4662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 10G 0306-530-000",
      "code_information": [
        {
          "code": "3559260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 642,
          "minimum": 219.4772,
          "maximum": 465.8994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 428.6274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ TRANS 0909-400-500",
      "code_information": [
        {
          "code": "3559261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 700,
          "minimum": 239.3054,
          "maximum": 1316.2887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 467.3508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 1025-011-500",
      "code_information": [
        {
          "code": "3559262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2367,
          "minimum": 335.8844,
          "maximum": 1717.7319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1580.3133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CEMENT 0306-410-000",
      "code_information": [
        {
          "code": "3559263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 604,
          "minimum": 206.4864,
          "maximum": 4504.9661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 403.257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INDIGO SEP12",
      "code_information": [
        {
          "code": "3559264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8101,
          "minimum": 1811.2177,
          "maximum": 5878.8957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5408.584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURRETTE-10G 0306-621-000",
      "code_information": [
        {
          "code": "3559265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3257,
          "minimum": 497.7095,
          "maximum": 2363.6049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2174.5165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FLEX CUFFED",
      "code_information": [
        {
          "code": "3559271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 750,
          "minimum": 256.3986,
          "maximum": 2534.7038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 500.733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-FLEXIBLE 2.9MM 682.622",
      "code_information": [
        {
          "code": "3559276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1344.635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2516H",
      "code_information": [
        {
          "code": "3559281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 69.435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COILED 60\\\" CT 100113",
      "code_information": [
        {
          "code": "3559287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 2641.475,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-GPS 3.5MM 6143.2572",
      "code_information": [
        {
          "code": "3559291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 3212.5897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2016.2849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4.2X360/SM 1320-3642S",
      "code_information": [
        {
          "code": "3559293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 959,
          "minimum": 327.8484,
          "maximum": 3425.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 640.2706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383593",
      "code_information": [
        {
          "code": "3559297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON BLK 4-0   1854G",
      "code_information": [
        {
          "code": "3559366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 59.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 PC-1  1855G",
      "code_information": [
        {
          "code": "3559390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 646.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER 4MM SB4000SA",
      "code_information": [
        {
          "code": "3559391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1162,
          "minimum": 99.5419,
          "maximum": 843.2634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 775.8023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING 19F L",
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        {
          "code": "3559394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 522.1779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.8025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCESS 8MM",
      "code_information": [
        {
          "code": "3559395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 939,
          "minimum": 50.049,
          "maximum": 681.4323,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 626.9177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
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        {
          "code": "3559401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1438,
          "minimum": 491.6017,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 960.0721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FIBERLASE CO2",
      "code_information": [
        {
          "code": "3559407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 5441.9946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3389.6286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER ELEVATE 8340155",
      "code_information": [
        {
          "code": "3559412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4241.3747,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0/PC-3  1865G",
      "code_information": [
        {
          "code": "3559425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 780.2083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MIC J FEDDING 8200",
      "code_information": [
        {
          "code": "3559430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 473.141,
          "maximum": 2490.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 924.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT SINGLE 5' RT219",
      "code_information": [
        {
          "code": "3559433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 377,
          "minimum": 128.8831,
          "maximum": 273.5889,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.7018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT DUAL HTDRT380",
      "code_information": [
        {
          "code": "3559434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 386,
          "minimum": 131.9598,
          "maximum": 452.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.7106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 EPM8706",
      "code_information": [
        {
          "code": "3559435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 814,
          "minimum": 278.278,
          "maximum": 590.7198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 543.4622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 2X315MM 703561",
      "code_information": [
        {
          "code": "3559445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 170.2487,
          "maximum": 6317.296,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 332.4867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VIZISNOT2 19G",
      "code_information": [
        {
          "code": "3559447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2067,
          "minimum": 212.4302,
          "maximum": 1500.0219,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1380.0201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIP 8.5X110 72200436",
      "code_information": [
        {
          "code": "3559448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 10602.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.04,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.100",
      "code_information": [
        {
          "code": "3559462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 751.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 K-WIRE",
      "code_information": [
        {
          "code": "3559463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 663.6381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 22X10MM 03.501.760",
      "code_information": [
        {
          "code": "3559485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2487,
          "minimum": 850.2179,
          "maximum": 1804.8159,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1660.4306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2590S",
      "code_information": [
        {
          "code": "3559495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 284,
          "minimum": 97.0896,
          "maximum": 206.0988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.6109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2591S",
      "code_information": [
        {
          "code": "3559496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 284,
          "minimum": 97.0896,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.6109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM GPS 6143.2580S",
      "code_information": [
        {
          "code": "3559499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1232.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM GPS 6143.2582S",
      "code_information": [
        {
          "code": "3559500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1232.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM GPS 6143.2584S",
      "code_information": [
        {
          "code": "3559501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1232.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 8FR G00980",
      "code_information": [
        {
          "code": "3559527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 7425.6033,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-6MM BALT 110135",
      "code_information": [
        {
          "code": "3559542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 710,
          "minimum": 242.7241,
          "maximum": 577.7879,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 474.0272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-OVASSAPIAN 85MM BD6075",
      "code_information": [
        {
          "code": "3559545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 1653.8414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/55 STANDARD 7607",
      "code_information": [
        {
          "code": "3559546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2974,
          "minimum": 721.8178,
          "maximum": 2158.2318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1985.5733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8013090",
      "code_information": [
        {
          "code": "3559559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5281.8378,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8340050",
      "code_information": [
        {
          "code": "3559560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9498,
          "minimum": 3247.0324,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6341.2827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y3/8X3/16X3/16 10518",
      "code_information": [
        {
          "code": "3559582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 6173.2661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CABLE 323.1090",
      "code_information": [
        {
          "code": "3559590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1886,
          "minimum": 644.7571,
          "maximum": 1368.6702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1259.1766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BRAD POINT 4MM 323.010",
      "code_information": [
        {
          "code": "3559591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2034,
          "minimum": 695.3531,
          "maximum": 9633.8764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1357.9879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRIPLE LUMEN 5.5FR",
      "code_information": [
        {
          "code": "3559593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1240,
          "minimum": 423.9124,
          "maximum": 899.868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 827.8786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL LUMEN 4FR",
      "code_information": [
        {
          "code": "3559594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1190,
          "minimum": 406.8192,
          "maximum": 34190.6963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 794.4964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 4.5X15 9009-2001",
      "code_information": [
        {
          "code": "3559598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3360,
          "minimum": 1148.6659,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2243.2838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM XT SIGTRSB45AXT",
      "code_information": [
        {
          "code": "3559607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2514,
          "minimum": 859.4483,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1678.457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/F P01-900-1902",
      "code_information": [
        {
          "code": "3559612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1805.977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/M P01-900-1903",
      "code_information": [
        {
          "code": "3559613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 3857.6657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1805.977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEE-UTILIZATION PER CASE",
      "code_information": [
        {
          "code": "3559626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4344,
          "minimum": 1485.061,
          "maximum": 3152.4408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2900.2455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.0MM 705360",
      "code_information": [
        {
          "code": "3559634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1250,
          "minimum": 427.3311,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 834.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SENSOR SPO2 1822A-25",
      "code_information": [
        {
          "code": "3559649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 687.8957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 86.1261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASO 12FR",
      "code_information": [
        {
          "code": "3559651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.1613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A435",
      "code_information": [
        {
          "code": "3559659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 393,
          "minimum": 134.3529,
          "maximum": 558.8805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.3841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #4 051114-10",
      "code_information": [
        {
          "code": "3559671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 82.7313,
          "maximum": 189.6301,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 161.5698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC",
      "code_information": [
        {
          "code": "3559672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 341,
          "minimum": 116.5759,
          "maximum": 1016.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 227.6666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 3.5X65",
      "code_information": [
        {
          "code": "3559673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1828,
          "minimum": 624.929,
          "maximum": 1326.5796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1220.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURETTE-0* TIP TDC005",
      "code_information": [
        {
          "code": "3559688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1582.7517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1456.1316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-0* TIP NAVIGATION",
      "code_information": [
        {
          "code": "3559690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1980,
          "minimum": 676.8924,
          "maximum": 5458.1215,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1321.9351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON SILK    C-021-",
      "code_information": [
        {
          "code": "3560079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 7.7854,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.1437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PS-2/4-0   J496G",
      "code_information": [
        {
          "code": "3560474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 7.7854,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J492G",
      "code_information": [
        {
          "code": "3560778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 55.4145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J493G",
      "code_information": [
        {
          "code": "3560802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.0704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J494G",
      "code_information": [
        {
          "code": "3560836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 4-0  J-496-H",
      "code_information": [
        {
          "code": "3560879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 42.8163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-497-G",
      "code_information": [
        {
          "code": "3560893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 95.6492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-774-D",
      "code_information": [
        {
          "code": "3561255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 7.7854,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.8348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J762D",
      "code_information": [
        {
          "code": "3561415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 7.7854,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.5229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0        699H",
      "code_information": [
        {
          "code": "3561696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 7.7854,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y496G",
      "code_information": [
        {
          "code": "3562112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 7.7854,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 61.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y494G",
      "code_information": [
        {
          "code": "3562131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS-2    1666",
      "code_information": [
        {
          "code": "3562141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 40,
          "minimum": 13.6746,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 26.7058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8619G",
      "code_information": [
        {
          "code": "3562217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 7.7854,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8699G",
      "code_information": [
        {
          "code": "3562235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 7.7854,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIVERSAL*****",
      "code_information": [
        {
          "code": "3566070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 92.8896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-EAR DAVOL 3 OZ 529****",
      "code_information": [
        {
          "code": "3566353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 112.3322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 34.7175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CT FAST LOAD DUAL",
      "code_information": [
        {
          "code": "3566355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 66.732,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.8641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-PACK DUAL EMPOWERCTA",
      "code_information": [
        {
          "code": "3566380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 3586.845,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CRANIAL ACCESS  INSHITH",
      "code_information": [
        {
          "code": "3566755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2554,
          "minimum": 546.0902,
          "maximum": 1853.4378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1705.1628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MULTI PODUS 9274-56XX",
      "code_information": [
        {
          "code": "3566785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 982,
          "minimum": 74.5174,
          "maximum": 712.6374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 655.6264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NURSING SUPPLEMENTAL",
      "code_information": [
        {
          "code": "3566790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 89.4643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FECAL MANAGEMENT",
      "code_information": [
        {
          "code": "3566823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1240,
          "minimum": 40.5953,
          "maximum": 899.868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 827.8786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-REPLACEMENT FECAL MGMT",
      "code_information": [
        {
          "code": "3566824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 512.1681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3567605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 921,
          "minimum": 104.5468,
          "maximum": 668.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 614.9001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "THERMOSET-INJECTATE    4142403",
      "code_information": [
        {
          "code": "3568123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 3118.0527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 8.0MM",
      "code_information": [
        {
          "code": "3568561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.1016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 6.0MM",
      "code_information": [
        {
          "code": "3568562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 450,
          "minimum": 153.8392,
          "maximum": 326.565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 300.4398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3568563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 297.1016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 508,
          "minimum": 173.6673,
          "maximum": 368.6556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 339.1632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU UNCUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 99.5419,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4259105",
      "code_information": [
        {
          "code": "3568757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 380,
          "minimum": 84.5272,
          "maximum": 275.766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 253.7047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-NEONATAL   42634-05",
      "code_information": [
        {
          "code": "3568760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 121.7859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXISENSOR-PEDIATRIC D20",
      "code_information": [
        {
          "code": "3568762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 630.0613,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565200",
      "code_information": [
        {
          "code": "3569240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 387.3329,
          "maximum": 822.2181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 756.4407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565150",
      "code_information": [
        {
          "code": "3569242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 203.5326,
          "maximum": 822.2181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 756.4407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16 FR",
      "code_information": [
        {
          "code": "3569250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 366,
          "minimum": 125.1225,
          "maximum": 265.6062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.3577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18 FR",
      "code_information": [
        {
          "code": "3569252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 366,
          "minimum": 11.122,
          "maximum": 265.6062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 244.3577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH URETHRAL BARD 772415",
      "code_information": [
        {
          "code": "3569258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 20,
          "minimum": 6.8373,
          "maximum": 608.9295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 13.3529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-ESOPH TRACH     5-18541",
      "code_information": [
        {
          "code": "3569601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1095,
          "minimum": 40.5953,
          "maximum": 794.6415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 731.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY CATH/DRN BAG 6176LL",
      "code_information": [
        {
          "code": "3569779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR   6146LL",
      "code_information": [
        {
          "code": "3569805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/ BAG 18FR  6148LL",
      "code_information": [
        {
          "code": "3569853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 77.6499,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 71.4379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG LTX 16F 6165L",
      "code_information": [
        {
          "code": "3569870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LOOP CCL DYNJ50892",
      "code_information": [
        {
          "code": "3570230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 202.9638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMBAR PUNCTURE ADT 4301C",
      "code_information": [
        {
          "code": "3570322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 69.5125,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMB PUNC PED   4304C****",
      "code_information": [
        {
          "code": "3570330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 310.3038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.4555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR PROC OP DYNJ31942F",
      "code_information": [
        {
          "code": "3570410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 65.0637,
          "maximum": 404.9406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 372.5454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PARA/PUD PHARMASEAL 4540A",
      "code_information": [
        {
          "code": "3570603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 540.5292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 6.0F",
      "code_information": [
        {
          "code": "3570605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 705.3804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 648.95,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 8.3F",
      "code_information": [
        {
          "code": "3570610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1211,
          "minimum": 382.0407,
          "maximum": 878.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 808.5169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SINGLE TAP BLOCK SPEC015",
      "code_information": [
        {
          "code": "3570640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 687,
          "minimum": 234.8612,
          "maximum": 498.5559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 458.6714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-NICU UMBILICAL CATH",
      "code_information": [
        {
          "code": "3570745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 543,
          "minimum": 185.6326,
          "maximum": 394.0551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 362.5307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-THORACENTESIS CURITY 5014*",
      "code_information": [
        {
          "code": "3571304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 404.8408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.2756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 16FR 0100-16LV",
      "code_information": [
        {
          "code": "3571985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 87.8638,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 252.3694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING W/ST 10F 43\\\"",
      "code_information": [
        {
          "code": "3571990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 177.952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 8.0     86552",
      "code_information": [
        {
          "code": "3572176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 413.1823,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 213.6461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 6LPC",
      "code_information": [
        {
          "code": "3572189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 743,
          "minimum": 201.8643,
          "maximum": 539.1951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 496.0595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 6CFS",
      "code_information": [
        {
          "code": "3572191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 281.9427,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 6MM",
      "code_information": [
        {
          "code": "3572195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 507,
          "minimum": 173.3255,
          "maximum": 559.9927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 338.4955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRP MIC-KEY 14FR 1.5CM",
      "code_information": [
        {
          "code": "3572305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 344.2579,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 672.3175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 35FR     125135",
      "code_information": [
        {
          "code": "3572307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 463.3449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 39FR     125139",
      "code_information": [
        {
          "code": "3572309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 463.3449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 41FR     125141",
      "code_information": [
        {
          "code": "3572311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 463.3449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 37FR LFT 125037",
      "code_information": [
        {
          "code": "3572315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 619,
          "minimum": 211.6143,
          "maximum": 1485.8992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 413.2716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BLAKEMORE 20 FR      9210",
      "code_information": [
        {
          "code": "3572344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2672,
          "minimum": 40.5953,
          "maximum": 1939.0704,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1783.9448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 5F 20\\\"     461412",
      "code_information": [
        {
          "code": "3572425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 6.5F 36\\\"   461438",
      "code_information": [
        {
          "code": "3572430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 77.2979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASOGASTRIC 8FR",
      "code_information": [
        {
          "code": "3572485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 131.7957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.8025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 18FR 20CC",
      "code_information": [
        {
          "code": "3572530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 237,
          "minimum": 48.3807,
          "maximum": 171.9909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 158.2316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.5       86215",
      "code_information": [
        {
          "code": "3572860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.0       8621",
      "code_information": [
        {
          "code": "3572863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.0       86212",
      "code_information": [
        {
          "code": "3572865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.5       86213",
      "code_information": [
        {
          "code": "3572866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 8.0C      86216",
      "code_information": [
        {
          "code": "3572867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "3573037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "3573039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 393.1627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41.3939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM",
      "code_information": [
        {
          "code": "3573355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 472.0243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 8MM",
      "code_information": [
        {
          "code": "3573357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 472.0243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF    SZs  DCTs",
      "code_information": [
        {
          "code": "3573530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 461,
          "minimum": 157.5997,
          "maximum": 334.5477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 307.7839,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FENESTRATED SZ 4TO10  CFN",
      "code_information": [
        {
          "code": "3573565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 1622.6998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 229.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH #6   518035",
      "code_information": [
        {
          "code": "3573650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 413.1823,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1948.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 8FR     8LPC",
      "code_information": [
        {
          "code": "3573714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 743,
          "minimum": 177.952,
          "maximum": 539.1951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 496.0595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,TRAC REINFO 6.0 86548",
      "code_information": [
        {
          "code": "3573730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 213.6461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 7.0     86550",
      "code_information": [
        {
          "code": "3573735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 237.4547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 213.6461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEEY PED",
      "code_information": [
        {
          "code": "3573845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 427,
          "minimum": 145.9763,
          "maximum": 324.2063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 285.084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 583,
          "minimum": 199.3072,
          "maximum": 423.0831,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 389.2365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 520,
          "minimum": 177.7697,
          "maximum": 377.364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 347.1749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 0.8MM",
      "code_information": [
        {
          "code": "3573906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 501,
          "minimum": 171.2743,
          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 334.4896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3573910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 435,
          "minimum": 148.7112,
          "maximum": 315.6795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 290.4251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF BLU 10.0MM",
      "code_information": [
        {
          "code": "3573911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 6.0MM",
      "code_information": [
        {
          "code": "3573914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 778.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 6.0MM",
      "code_information": [
        {
          "code": "3573915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1400,
          "minimum": 478.6108,
          "maximum": 1015.98,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 934.7016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 8.0MM",
      "code_information": [
        {
          "code": "3573916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 229.6693,
          "maximum": 816.4125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 751.0995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF 7.0MM",
      "code_information": [
        {
          "code": "3573920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 413,
          "minimum": 141.1902,
          "maximum": 373.6992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 275.737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 60A160",
      "code_information": [
        {
          "code": "3573926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 672,
          "minimum": 229.7332,
          "maximum": 487.6704,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 448.6568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 7MM",
      "code_information": [
        {
          "code": "3573937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE XL 7",
      "code_information": [
        {
          "code": "3573950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 40.5953,
          "maximum": 816.4125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 751.0995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNDERPAD-CGLIDE XL 40X80 PK",
      "code_information": [
        {
          "code": "3574527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 69.5125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-D&C COLLECTION 23116",
      "code_information": [
        {
          "code": "3574563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 367.5821,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 83.4555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-MITY-ONE MYSTIC   10058",
      "code_information": [
        {
          "code": "3574642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 661,
          "minimum": 33.9221,
          "maximum": 479.6877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 441.3127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI-REFLUX",
      "code_information": [
        {
          "code": "3574651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 488.8119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING TRACH    PMV007",
      "code_information": [
        {
          "code": "3574654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 879,
          "minimum": 300.4992,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 586.8591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAX-BONE                  W31G",
      "code_information": [
        {
          "code": "3575105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 152.3714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.0821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER PK",
      "code_information": [
        {
          "code": "3575110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 230.2254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.9345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER XLPK",
      "code_information": [
        {
          "code": "3575115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 414,
          "minimum": 77.2979,
          "maximum": 300.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 276.4046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-FOAM POSITIONING DISP",
      "code_information": [
        {
          "code": "3575122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 180.1764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.8025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MEDTRONIC ATRIAL    6492F",
      "code_information": [
        {
          "code": "3575572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 99.5419,
          "maximum": 235.1268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.3167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK L/XL",
      "code_information": [
        {
          "code": "3575890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 235.8525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.9843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-THROMBIDISC TOPICAL HEMO",
      "code_information": [
        {
          "code": "3575891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 230.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.2522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD S/M",
      "code_information": [
        {
          "code": "3575892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 301.1655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 277.0723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD L/XL",
      "code_information": [
        {
          "code": "3575893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 518,
          "minimum": 177.086,
          "maximum": 375.9126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.8396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-LEG POSITIONER 111618",
      "code_information": [
        {
          "code": "3575894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 229.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK S/M",
      "code_information": [
        {
          "code": "3575895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 30.5855,
          "maximum": 196.6647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRISTLET-PORTHOLE 6600021150",
      "code_information": [
        {
          "code": "3576870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 36.7204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH 442-2",
      "code_information": [
        {
          "code": "3576880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 41.1514,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EXUDE HYDRO 6X6",
      "code_information": [
        {
          "code": "3580000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.4057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-OPTICELL AG+4X5",
      "code_information": [
        {
          "code": "3580001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 104.5468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 91.4672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 16FR",
      "code_information": [
        {
          "code": "3580005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST RT XS 8",
      "code_information": [
        {
          "code": "3580008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.8142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LT XS 8",
      "code_information": [
        {
          "code": "3580009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 102.8785,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.1231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 EASY CAP II",
      "code_information": [
        {
          "code": "3580015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 171,
          "minimum": 58.4589,
          "maximum": 124.0947,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.1671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 14FR",
      "code_information": [
        {
          "code": "3580016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 145.6982,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-NASAL L/R STANDARD",
      "code_information": [
        {
          "code": "3580017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 262,
          "minimum": 47.2685,
          "maximum": 190.1334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 174.9227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT MED CLOSED",
      "code_information": [
        {
          "code": "3580023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 100.098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,OVAL 5.5X13CM AR-8550COE",
      "code_information": [
        {
          "code": "3580025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 815.7987,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.1104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3590000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1467,
          "minimum": 210.2058,
          "maximum": 1064.6019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 979.4337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTROSTOMY 18FR   100-18",
      "code_information": [
        {
          "code": "3590008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 252.3694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY BASIC         4380",
      "code_information": [
        {
          "code": "3590013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 301,
          "minimum": 102.9013,
          "maximum": 218.4357,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 200.9608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSAL 10FR  15642-001",
      "code_information": [
        {
          "code": "3590100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 385.3773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REPAIR ASH CATH      RPK01",
      "code_information": [
        {
          "code": "3590134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 693,
          "minimum": 207.4253,
          "maximum": 502.9101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 462.6773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 99.5419,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.0195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LMH LMH-1001",
      "code_information": [
        {
          "code": "3598009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 207.4253,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1792.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 03.130.302",
      "code_information": [
        {
          "code": "3598013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 2920.6372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-BLUE RHINO G2",
      "code_information": [
        {
          "code": "3598017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1904.7883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-STERLING 3.0X60X150",
      "code_information": [
        {
          "code": "3598023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1841,
          "minimum": 41.7075,
          "maximum": 1336.0137,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1229.1326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORGANIZER-7 DAY PILL 70069L",
      "code_information": [
        {
          "code": "3598024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 78.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.0733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I-KNIFE II 8065921502",
      "code_information": [
        {
          "code": "3598025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 142,
          "minimum": 48.5448,
          "maximum": 103.0494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.8054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPEN KNEE ABS-2001-OT",
      "code_information": [
        {
          "code": "3598069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 4266.3992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3201.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE GEL",
      "code_information": [
        {
          "code": "3598076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 41.1514,
          "maximum": 181.425,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 166.911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACEMENT GEL",
      "code_information": [
        {
          "code": "3598077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 139.025,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.4057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER GEL",
      "code_information": [
        {
          "code": "3598078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 85.4662,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 166.911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-SAMPLE EXTENSION 1841-25",
      "code_information": [
        {
          "code": "3598081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 6399.5988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 116.1701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-8MM ENT TUBE NVM5 2010480",
      "code_information": [
        {
          "code": "3598086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2289,
          "minimum": 782.5287,
          "maximum": 15669.2297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1528.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-9WX7L AR-8717-0907",
      "code_information": [
        {
          "code": "3598104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 32790.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-MEGADYNE 10FT SMOKE",
      "code_information": [
        {
          "code": "3598109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 55.61,
          "maximum": 169.0881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 155.5611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MEGADYNE F/SMOKE",
      "code_information": [
        {
          "code": "3598110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 196.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.7644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ZIP PEN F/SMOKE EVAC",
      "code_information": [
        {
          "code": "3598111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 121.0202,
          "maximum": 310.8599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 236.346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER SO SPECTRUM SU",
      "code_information": [
        {
          "code": "3598112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 191.1025,
          "maximum": 405.6663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 373.213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER S1 SPECTRUM SU",
      "code_information": [
        {
          "code": "3598113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 33.9221,
          "maximum": 405.6663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 373.213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1603G",
      "code_information": [
        {
          "code": "3598114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 1661G",
      "code_information": [
        {
          "code": "3598115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.4057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MINIVAC MGVSFT10",
      "code_information": [
        {
          "code": "3598117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 454.8898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.1349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHTMAT-ULTRATHIN UA2550",
      "code_information": [
        {
          "code": "3598118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 818,
          "minimum": 279.6455,
          "maximum": 593.6226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 546.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MEGADYN SPECULUM 23951",
      "code_information": [
        {
          "code": "3598134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.8641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-221C-0427",
      "code_information": [
        {
          "code": "3598154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 5197.8667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 531.4446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLIDE-OCULAR KDB GLIDE",
      "code_information": [
        {
          "code": "3598156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 207.4253,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2217.9134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROVU DISP PHB-03",
      "code_information": [
        {
          "code": "3598158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11119,
          "minimum": 1230.6493,
          "maximum": 8069.0583,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7423.5336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BLUGRIGGS PERC DILATION",
      "code_information": [
        {
          "code": "3598159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2213,
          "minimum": 756.5469,
          "maximum": 5157.8275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1477.4962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5X10 AR-8610TDC-01C",
      "code_information": [
        {
          "code": "3598172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 12007.8673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1568.2958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-EGG 4.0MM 5820-015-040",
      "code_information": [
        {
          "code": "3598178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 2.0 6007-1200",
      "code_information": [
        {
          "code": "3598184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 4999.339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 648.2823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY SZ 8 8DCFS",
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        {
          "code": "3598187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.04,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBT 7MM EMG ET 2010470",
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        {
          "code": "3598201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2289,
          "minimum": 782.5287,
          "maximum": 1661.1273,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1528.2371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LAPIPLASTY 40X11 SM-4011",
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        {
          "code": "3598213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 3.2 HAMMER 702632",
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        {
          "code": "3598233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4242,
          "minimum": 870.8526,
          "maximum": 3078.4194,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2832.1458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK DS AR-8991DS",
      "code_information": [
        {
          "code": "3598238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1938,
          "minimum": 662.5341,
          "maximum": 4743.533,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1293.8941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 PLUS VCP317H",
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        {
          "code": "3598242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6.6764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM CSS-072-37-SQ",
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        {
          "code": "3598257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1052.9907,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 968.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-25 G00896",
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        {
          "code": "3598279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 193,
          "minimum": 65.9799,
          "maximum": 1556.5239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 128.8553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HIGH TORQUE 70-2001",
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        {
          "code": "3598282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1378,
          "minimum": 36.7026,
          "maximum": 1000.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 920.0134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP523H",
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        {
          "code": "3598283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.0645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.3MM AR-7535",
      "code_information": [
        {
          "code": "3598289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 1101.078,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 498.7301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYNGECTOMY SZ10 6132",
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        {
          "code": "3598291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2343,
          "minimum": 46.7124,
          "maximum": 1700.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1564.2899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-PREFILL AREOSOL 500M",
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        {
          "code": "3598292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.0821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUNCTURE 17FR/10MM 8141US",
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        {
          "code": "3598296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 921.3258,
          "maximum": 8230.28,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1799.3006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORCAPOD SUCTION BIOPSY",
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        {
          "code": "3598300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 46.1563,
          "maximum": 116.8377,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 107.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-E-Z CLEAN 0016AM",
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        {
          "code": "3598301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 28.3748,
          "maximum": 6499.6968,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 55.4145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL 80M 04.038.380S",
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        {
          "code": "3598333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1530.8708,
          "maximum": 3249.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2989.7098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153204",
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        {
          "code": "3598338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 38.2889,
          "maximum": 8315.3633,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 SURGILON 8886195151",
      "code_information": [
        {
          "code": "3598362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 42.8163,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 39.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 SURGILON 8886195141",
      "code_information": [
        {
          "code": "3598363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.4057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEO TEE 1050810",
      "code_information": [
        {
          "code": "3598397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 209.0016,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 192.2815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 10.5 CLR",
      "code_information": [
        {
          "code": "3598403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 201.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 42.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY L-WIRE 20115",
      "code_information": [
        {
          "code": "3598404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 362,
          "minimum": 123.7551,
          "maximum": 345.3381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-LIGATING SURGITIE SGL-1",
      "code_information": [
        {
          "code": "3598405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 621,
          "minimum": 7.7854,
          "maximum": 450.6597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 414.6069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 11 96\\\" Z880G",
      "code_information": [
        {
          "code": "3598407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 1146.6782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-POWER 45MM FLEX PSEE45",
      "code_information": [
        {
          "code": "3598408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2062,
          "minimum": 31.6977,
          "maximum": 1496.3934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1376.6819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 32FR 056132",
      "code_information": [
        {
          "code": "3598409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 126.7908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SOFSIK 2-0 18\\\" GS63M",
      "code_information": [
        {
          "code": "3598410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 7.7854,
          "maximum": 165.4596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.2228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOSOF 5-0 SN-661",
      "code_information": [
        {
          "code": "3598412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 81.7467,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1 G48",
      "code_information": [
        {
          "code": "3598413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 7.7854,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 98.1437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0 3844G",
      "code_information": [
        {
          "code": "3598415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.1349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 714G",
      "code_information": [
        {
          "code": "3598417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD WARMING RAPID 24355",
      "code_information": [
        {
          "code": "3598418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 134.5762,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 295.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTOLOGY 2.3MMX240CM",
      "code_information": [
        {
          "code": "3598419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 78.4101,
          "maximum": 175.6194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 161.5698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY LONG 2.4MM E1450-6",
      "code_information": [
        {
          "code": "3598420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 7.7854,
          "maximum": 102.3237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.1378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y527H",
      "code_information": [
        {
          "code": "3598424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 239.123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-GRAVITY SPIKE FLUID MGMT",
      "code_information": [
        {
          "code": "3598425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 127.3469,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEM SILVER 6.5X7",
      "code_information": [
        {
          "code": "3598426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 166.1853,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.8905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 20FR 5CC",
      "code_information": [
        {
          "code": "3598427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 183.513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 94.1378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-J-TIP .035X145CM",
      "code_information": [
        {
          "code": "3598428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 330,
          "minimum": 81.1906,
          "maximum": 239.481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 220.3225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 30CC 16FR",
      "code_information": [
        {
          "code": "3598429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 97.476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2 490T",
      "code_information": [
        {
          "code": "3598434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII BLADED CTB33",
      "code_information": [
        {
          "code": "3598436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM BLADELESS CTR03",
      "code_information": [
        {
          "code": "3598437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND 10FR DYNJWE1321A",
      "code_information": [
        {
          "code": "3598439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.7732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ULNAR NERVE 79-91100",
      "code_information": [
        {
          "code": "3598441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 947.0383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 43.3969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POWDER-HEMOSTAT AVITENE 1 GRAM",
      "code_information": [
        {
          "code": "3598442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1703,
          "minimum": 362.5772,
          "maximum": 1235.8671,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1136.9977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RADIAL ARTERY 20GX1.75\\\"",
      "code_information": [
        {
          "code": "3598444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 265,
          "minimum": 90.5942,
          "maximum": 464.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 176.9257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL RHINO ROCKET LRG",
      "code_information": [
        {
          "code": "3598446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 368.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-FOREIGN BODY 60613",
      "code_information": [
        {
          "code": "3598447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 663,
          "minimum": 31.6977,
          "maximum": 481.1391,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 442.648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 24FR 056124",
      "code_information": [
        {
          "code": "3598448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 121.2298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-HYDROFERA 6X6 HB6614",
      "code_information": [
        {
          "code": "3598449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 158.2026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 145.5464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SMALL WIDE",
      "code_information": [
        {
          "code": "3598450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 254.1377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARYNGECTOMY SZ6 6LGT",
      "code_information": [
        {
          "code": "3598451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 457,
          "minimum": 156.2322,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 305.1133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X285MM 703586",
      "code_information": [
        {
          "code": "3598458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 566,
          "minimum": 193.4955,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.8865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 566,
          "minimum": 193.4955,
          "maximum": 471.5728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 377.8865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 18FR",
      "code_information": [
        {
          "code": "3598463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 711.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.2911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 384.598,
          "maximum": 4441.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 751.0995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATFORM-GELPOINT PATH CNB11",
      "code_information": [
        {
          "code": "3598471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1687.4449,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3295.4908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VINYL CONNECTING G02791",
      "code_information": [
        {
          "code": "3598473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 78.9708,
          "maximum": 179.6203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 154.2258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRUIT, CROSS VENT 80011",
      "code_information": [
        {
          "code": "3598474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 323,
          "minimum": 110.4223,
          "maximum": 234.4011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 215.649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR, NEO W/MASK",
      "code_information": [
        {
          "code": "3598475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 342,
          "minimum": 116.9178,
          "maximum": 533.2999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 228.3342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3598478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 71.1808,
          "maximum": 565.3203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 520.0947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC #1 48G",
      "code_information": [
        {
          "code": "3598479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3287.6632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STEM 222-496100",
      "code_information": [
        {
          "code": "3598480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5912,
          "minimum": 2021.1051,
          "maximum": 4290.3384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3947.1113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRIP-PLATINUM MS04R-IP10X-0JH",
      "code_information": [
        {
          "code": "3598481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4118,
          "minimum": 1407.7995,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2749.358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-ENDOCAPSULE 10 MAJ2027",
      "code_information": [
        {
          "code": "3598483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3003,
          "minimum": 402.6164,
          "maximum": 2179.2771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2004.9349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-10G/7.75\\\" 0306-810-000",
      "code_information": [
        {
          "code": "3598484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 724,
          "minimum": 247.5102,
          "maximum": 525.4068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 483.3743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77420",
      "code_information": [
        {
          "code": "3598485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 584,
          "minimum": 199.6491,
          "maximum": 30448.6994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 389.9041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/SUPPORT #6",
      "code_information": [
        {
          "code": "3598487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 784,
          "minimum": 268.0221,
          "maximum": 568.9488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 523.4329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST 4050-100N",
      "code_information": [
        {
          "code": "3598488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 1676.0854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 471.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-GONIOTOMY TRABEX 600042",
      "code_information": [
        {
          "code": "3598489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3014,
          "minimum": 784.101,
          "maximum": 2187.2598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2012.279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-STRAIGHT JAW NSLX137S",
      "code_information": [
        {
          "code": "3598493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2542,
          "minimum": 869.0205,
          "maximum": 1844.7294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1697.151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW NSLX137C",
      "code_information": [
        {
          "code": "3598494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2637,
          "minimum": 901.4976,
          "maximum": 1913.6709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1760.5772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JADA POSTPARTUM",
      "code_information": [
        {
          "code": "3598497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5844,
          "minimum": 1997.8582,
          "maximum": 5012.6854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3901.7115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA G PROCEDURAL PUG",
      "code_information": [
        {
          "code": "3598498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9014,
          "minimum": 580.0123,
          "maximum": 6541.4598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6018.143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-4MM/SHORT 1149.8052",
      "code_information": [
        {
          "code": "3598502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 872.0973,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1703.1598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN",
      "code_information": [
        {
          "code": "3598508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94975",
      "code_information": [
        {
          "code": "3598515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1030,
          "minimum": 352.1208,
          "maximum": 747.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 687.6733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYN W/EL SZ10 6136",
      "code_information": [
        {
          "code": "3598520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4004,
          "minimum": 245.7962,
          "maximum": 2905.7028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2673.2466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.4X100/LG AGK10100",
      "code_information": [
        {
          "code": "3598521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 1475.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 295.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X120MM 45302001",
      "code_information": [
        {
          "code": "3598524",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 263.0517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNIT-TI-KNOT QUICK LOAD 030510",
      "code_information": [
        {
          "code": "3598527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PICO 14 WOUND 15X30CM",
      "code_information": [
        {
          "code": "3598530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1724,
          "minimum": 589.375,
          "maximum": 1251.1068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1151.0183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1590,
          "minimum": 543.5651,
          "maximum": 2600.3236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1061.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY STANDARD 7607",
      "code_information": [
        {
          "code": "3598534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1347,
          "minimum": 42.8197,
          "maximum": 977.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 899.3165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND XTRASORB 6X9",
      "code_information": [
        {
          "code": "3598535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 1016.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1828,
          "minimum": 32.2538,
          "maximum": 1326.5796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1220.4532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS SELECT",
      "code_information": [
        {
          "code": "3598538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 831.9256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY",
      "code_information": [
        {
          "code": "3598539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1496,
          "minimum": 511.4298,
          "maximum": 1085.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 998.7954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LK/MD 3.1X328 705077",
      "code_information": [
        {
          "code": "3598547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1526,
          "minimum": 207.4253,
          "maximum": 1107.4182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1018.8247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E-CATH PLUS 251285-41E",
      "code_information": [
        {
          "code": "3598551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 14240.6088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-OVAL CUP BIOPSY SINGLE",
      "code_information": [
        {
          "code": "3598561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 424.5345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 390.5717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEATED W/GAS FILTER",
      "code_information": [
        {
          "code": "3598562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 652,
          "minimum": 222.8959,
          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 435.3039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-10X360/RT/130* 3430-0360S",
      "code_information": [
        {
          "code": "3598565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6277,
          "minimum": 933.1358,
          "maximum": 4555.2189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4190.8014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X65MM 03.130.201",
      "code_information": [
        {
          "code": "3598592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1114,
          "minimum": 380.8375,
          "maximum": 808.4298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 743.7554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTERD FURCATED ASM-EVAC",
      "code_information": [
        {
          "code": "3598594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1123,
          "minimum": 383.9142,
          "maximum": 1056.59,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 749.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS + MAP152",
      "code_information": [
        {
          "code": "3598601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 1228.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.8641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRIVE T6 VARIAX2 705132",
      "code_information": [
        {
          "code": "3598602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2210,
          "minimum": 755.5213,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1475.4932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREW T7 AO 45-27015",
      "code_information": [
        {
          "code": "3598609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1540,
          "minimum": 526.4719,
          "maximum": 3684.1625,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1028.1718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROXIMATE PROCEDURE PPH03",
      "code_information": [
        {
          "code": "3598617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2668,
          "minimum": 556.6561,
          "maximum": 1936.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1781.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X7MM 60-16007",
      "code_information": [
        {
          "code": "3598624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1349,
          "minimum": 461.1757,
          "maximum": 1138.3367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 900.6518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.9X115/35MM 92-19135",
      "code_information": [
        {
          "code": "3598625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2047,
          "minimum": 699.7974,
          "maximum": 1485.5079,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1366.6673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 9787.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.4702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 4627.8642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 175.5904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-EDIPURAL 17GX3.5 BUPIV",
      "code_information": [
        {
          "code": "3598647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 362,
          "minimum": 99.5419,
          "maximum": 262.7034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 0.3MM DWD055",
      "code_information": [
        {
          "code": "3598653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1389,
          "minimum": 207.4253,
          "maximum": 1007.9973,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 927.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #2",
      "code_information": [
        {
          "code": "3598662",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 90.0882,
          "maximum": 600.8796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 552.8092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDICLE ACCESS 624.027S",
      "code_information": [
        {
          "code": "3598668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 1542.8361,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3013.0774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3598678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 974,
          "minimum": 270.2646,
          "maximum": 706.8318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 650.2853,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 24FR 77424",
      "code_information": [
        {
          "code": "3598679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 486,
          "minimum": 166.1463,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 324.475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X13MM AR-300-B001",
      "code_information": [
        {
          "code": "3598688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2343,
          "minimum": 800.9894,
          "maximum": 1700.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1564.2899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X19.5MM AR-300-B201",
      "code_information": [
        {
          "code": "3598689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2396,
          "minimum": 819.1082,
          "maximum": 1738.7772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1599.675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8710H",
      "code_information": [
        {
          "code": "3598695",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 272,
          "minimum": 92.9872,
          "maximum": 214.0985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.5992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8725H",
      "code_information": [
        {
          "code": "3598696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 385,
          "minimum": 131.618,
          "maximum": 279.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 257.0429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8806H",
      "code_information": [
        {
          "code": "3598697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 213.6461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8718H",
      "code_information": [
        {
          "code": "3598698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 187.2306,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 172.2522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8714H",
      "code_information": [
        {
          "code": "3598699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 215,
          "minimum": 73.5009,
          "maximum": 460.4508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 143.5435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W SPPRT MXPRSK05",
      "code_information": [
        {
          "code": "3598700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 283.0641,
          "maximum": 31654.8803,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 552.8092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-BENSTON 260CM/.035\\\"",
      "code_information": [
        {
          "code": "3598702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 141.5405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/ SUPPORT #3",
      "code_information": [
        {
          "code": "3598704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 283.0641,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 552.8092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-LT 130°/10X420 3530-0420S",
      "code_information": [
        {
          "code": "3598705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6277,
          "minimum": 2145.8857,
          "maximum": 4555.2189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4190.8014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-XI 45MM 480445",
      "code_information": [
        {
          "code": "3598714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3242,
          "minimum": 7.7854,
          "maximum": 2352.7194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2164.5018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-MUSTANG 7.0X20X135CM",
      "code_information": [
        {
          "code": "3598729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 909.3311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT,ACTIVE ANKLE HEEL-LOCK",
      "code_information": [
        {
          "code": "3598758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 464,
          "minimum": 150.7031,
          "maximum": 336.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 309.7868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR,SURGICEL 3123SPEA",
      "code_information": [
        {
          "code": "3598761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 322,
          "minimum": 110.0805,
          "maximum": 2901.7298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.9814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP ESREC",
      "code_information": [
        {
          "code": "3598782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 3.0X2.1 45-30005",
      "code_information": [
        {
          "code": "3598799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1849,
          "minimum": 632.1081,
          "maximum": 1341.8193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1234.4738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAC 425840405",
      "code_information": [
        {
          "code": "3598801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.5024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-8737-37",
      "code_information": [
        {
          "code": "3598812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE,.045\\\" THD AR-8737-05",
      "code_information": [
        {
          "code": "3598815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 7942.7763,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO 2.0MM DC6106",
      "code_information": [
        {
          "code": "3598843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 199.0838,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1165.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.5X150MM 58862515",
      "code_information": [
        {
          "code": "3598844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM DSDS1011",
      "code_information": [
        {
          "code": "3598845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.5MM DSDS0025",
      "code_information": [
        {
          "code": "3598846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1272.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.0MM DSDS0030",
      "code_information": [
        {
          "code": "3598853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1272.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR SHEEHY 510-131C",
      "code_information": [
        {
          "code": "3598870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 148.7685,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F X-FIT 60-80323",
      "code_information": [
        {
          "code": "3598874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1052.9907,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 968.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F 1.7MM 60-80317",
      "code_information": [
        {
          "code": "3598875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 968.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EAR-SPEEDIWICK 15MM OT-5201-50",
      "code_information": [
        {
          "code": "3598882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 15CM APYX-15-TP",
      "code_information": [
        {
          "code": "3598955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3007,
          "minimum": 1027.9876,
          "maximum": 2182.1799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2007.6055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERIOTOMY",
      "code_information": [
        {
          "code": "3598957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 207.4253,
          "maximum": 640.7931,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 589.5297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/46-62\\\" 1143PP",
      "code_information": [
        {
          "code": "3598975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.7791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 6.0 BIPOLAR",
      "code_information": [
        {
          "code": "3598997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2604,
          "minimum": 890.2161,
          "maximum": 3668.0356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1738.545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 004025",
      "code_information": [
        {
          "code": "3599029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 91.4382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.1231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-WIGGLE OPTIFLOW JR 2 M",
      "code_information": [
        {
          "code": "3599030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 10911.2381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.65MM MD 45303065",
      "code_information": [
        {
          "code": "3599049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.55MM MD 45303055",
      "code_information": [
        {
          "code": "3599050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8305H",
      "code_information": [
        {
          "code": "3599073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 1132.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 151.5552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-S-CURVE URETH DIL G32789",
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        {
          "code": "3599074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2036,
          "minimum": 696.0369,
          "maximum": 1477.5252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1359.3232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5x57MM 03.130.211",
      "code_information": [
        {
          "code": "3599095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
      "code_information": [
        {
          "code": "3599096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5613,
          "minimum": 1918.8875,
          "maximum": 4073.3541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3747.4858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002352",
      "code_information": [
        {
          "code": "3599098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2262,
          "minimum": 773.2983,
          "maximum": 1641.5334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1510.2107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002351",
      "code_information": [
        {
          "code": "3599099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2262,
          "minimum": 773.2983,
          "maximum": 1641.5334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1510.2107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-BEADED 3MM 4150004030",
      "code_information": [
        {
          "code": "3599100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1947,
          "minimum": 665.6109,
          "maximum": 1412.9379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1299.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LONG ENCOMPASS JAW OLH",
      "code_information": [
        {
          "code": "3599110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 22744,
          "minimum": 7775.3744,
          "maximum": 16505.3208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 15184.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
      "code_information": [
        {
          "code": "3599114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4881,
          "minimum": 1668.6424,
          "maximum": 3600.7475,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3258.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-270-330C ALLOX-FH12SE",
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        {
          "code": "3599115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6475,
          "minimum": 207.4253,
          "maximum": 4698.9075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4322.9949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.3MM CSS-040-23",
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        {
          "code": "3599133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 9651.6716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 219.6549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-NAIL 3MM 4150004025",
      "code_information": [
        {
          "code": "3599135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1947,
          "minimum": 665.6109,
          "maximum": 1412.9379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1299.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-FULL VIP1137430",
      "code_information": [
        {
          "code": "3599140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FILL VIP1137431",
      "code_information": [
        {
          "code": "3599141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 284,
          "minimum": 97.0896,
          "maximum": 206.0988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 189.6109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #4",
      "code_information": [
        {
          "code": "3599144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 870,
          "minimum": 297.4224,
          "maximum": 631.359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 580.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-HINGED KNEE LG 11-0672-4",
      "code_information": [
        {
          "code": "3599145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 872,
          "minimum": 207.4253,
          "maximum": 632.8104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 582.1856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-PROCESSOR DEPTH Z179994",
      "code_information": [
        {
          "code": "3599155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2423,
          "minimum": 828.3386,
          "maximum": 32205.4193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1617.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X230/200MM 315.93",
      "code_information": [
        {
          "code": "3599157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1826,
          "minimum": 624.2452,
          "maximum": 11446.7624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1219.1179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TENSIONER-CERCLAGE AR-7820",
      "code_information": [
        {
          "code": "3599172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2030,
          "minimum": 693.9857,
          "maximum": 1473.171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1355.3173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CERCLAGE STR/LG AR-7822",
      "code_information": [
        {
          "code": "3599173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 533.2999,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1108.9567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-INS MID/HINDFOOT FFSP1530",
      "code_information": [
        {
          "code": "3599178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 4705.7182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1680.4599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LP PRP LEUKOCYTE POOR PRS6",
      "code_information": [
        {
          "code": "3599190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3723,
          "minimum": 1272.7629,
          "maximum": 2701.7811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2485.6386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-4160-40",
      "code_information": [
        {
          "code": "3599227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 398.1676,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SET RENOVARP GIS-30",
      "code_information": [
        {
          "code": "3599230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 5458.1215,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/135X45 03.133.102",
      "code_information": [
        {
          "code": "3599237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1522,
          "minimum": 274.1573,
          "maximum": 1104.5154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1016.1542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-100.783+/3H 954-0035",
      "code_information": [
        {
          "code": "3599249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1448,
          "minimum": 423.7482,
          "maximum": 1050.8136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 966.7485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PARACENTESIS GIS-31",
      "code_information": [
        {
          "code": "3599291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 132.3518,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 627.5854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MALE EXT PWM-030 PUREWICK",
      "code_information": [
        {
          "code": "3599292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 238,
          "minimum": 40.0392,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 158.8993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 2 1/2\\\"",
      "code_information": [
        {
          "code": "3599298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.0704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 3\\\"",
      "code_information": [
        {
          "code": "3599299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-PLANTAR KERATOSIS WOMENS",
      "code_information": [
        {
          "code": "3599300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" SMALL",
      "code_information": [
        {
          "code": "3599306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" MEDIUM",
      "code_information": [
        {
          "code": "3599307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" LARGE",
      "code_information": [
        {
          "code": "3599308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 53.7018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.4057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE DOUBLE",
      "code_information": [
        {
          "code": "3599309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE SINGLE",
      "code_information": [
        {
          "code": "3599310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE LEFT",
      "code_information": [
        {
          "code": "3599311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 69.6672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE RIGHT",
      "code_information": [
        {
          "code": "3599312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 139.5811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 25GX5”",
      "code_information": [
        {
          "code": "3599313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 251,
          "minimum": 85.8081,
          "maximum": 576.6757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 167.5786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3599314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1037,
          "minimum": 354.5139,
          "maximum": 1007.6532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 692.3468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXYGENATOR-PERFUSION 050715",
      "code_information": [
        {
          "code": "3599315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1812,
          "minimum": 619.4591,
          "maximum": 1314.9684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1209.7709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-Y TYPE PERFUSION 10004",
      "code_information": [
        {
          "code": "3599362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 24440.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.4203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 19G X 1.5\\\"CT",
      "code_information": [
        {
          "code": "3599369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 1325.1863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM TUBING 8H23R12",
      "code_information": [
        {
          "code": "3599370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2383,
          "minimum": 814.664,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1590.9957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.7/125MM 03.133.105",
      "code_information": [
        {
          "code": "3599378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1325,
          "minimum": 452.9709,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 884.6283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-PIECE-OXYGEN MONITOR",
      "code_information": [
        {
          "code": "3599381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 5ML GIS-55",
      "code_information": [
        {
          "code": "3599412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 122.342,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-FINGER XL A8685",
      "code_information": [
        {
          "code": "3599413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 180.7325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.8817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY 040-300",
      "code_information": [
        {
          "code": "3599414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 811.906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 216.9843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RET 5MM/155CM FB-231D.A",
      "code_information": [
        {
          "code": "3599417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 6469.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/135X45 03.133.106",
      "code_information": [
        {
          "code": "3599424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1497,
          "minimum": 511.7717,
          "maximum": 1665.5195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 999.4631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL N8 PROCESSOR DUALN8",
      "code_information": [
        {
          "code": "3599512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62546,
          "minimum": 501.0461,
          "maximum": 45389.6322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 41758.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0 EPM8703",
      "code_information": [
        {
          "code": "3599513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 901,
          "minimum": 308.0202,
          "maximum": 1582.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 601.5472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.002",
      "code_information": [
        {
          "code": "3599527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 944,
          "minimum": 322.7204,
          "maximum": 48174.3869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 630.2559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOYSTICK-RED 5MM 03.211.454",
      "code_information": [
        {
          "code": "3599531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2911,
          "minimum": 497.7095,
          "maximum": 2112.5127,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1943.5117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IABC 40CC 7FR IMU7F-40",
      "code_information": [
        {
          "code": "3599539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5359,
          "minimum": 870.8526,
          "maximum": 3889.0263,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3577.9042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-SD 2MM T6 313.843.V",
      "code_information": [
        {
          "code": "3599548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1853,
          "minimum": 633.4756,
          "maximum": 1344.7221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1237.1443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIX 1.1MM DC4212",
      "code_information": [
        {
          "code": "3599593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1180,
          "minimum": 403.4005,
          "maximum": 1048.8046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 787.8199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 70MM",
      "code_information": [
        {
          "code": "3599601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.1964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 100MM",
      "code_information": [
        {
          "code": "3599602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 134.1964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE SMALL",
      "code_information": [
        {
          "code": "3599607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.8348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE MEDIUM",
      "code_information": [
        {
          "code": "3599608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.8348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE LARGE",
      "code_information": [
        {
          "code": "3599609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.8348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE X-LARGE",
      "code_information": [
        {
          "code": "3599610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 114.8348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 3520",
      "code_information": [
        {
          "code": "3599611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.8025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4030",
      "code_information": [
        {
          "code": "3599612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.8025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4540",
      "code_information": [
        {
          "code": "3599613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.8025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5040",
      "code_information": [
        {
          "code": "3599614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.8084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5550",
      "code_information": [
        {
          "code": "3599615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.8025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 35-40CM",
      "code_information": [
        {
          "code": "3599617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 293,
          "minimum": 100.1664,
          "maximum": 212.6301,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 195.6197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 40-45CM",
      "code_information": [
        {
          "code": "3599618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 293,
          "minimum": 100.1664,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 195.6197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE CVD AC-20055390",
      "code_information": [
        {
          "code": "3599638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1368,
          "minimum": 467.6711,
          "maximum": 992.7576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 913.337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE STRAIGHT",
      "code_information": [
        {
          "code": "3599639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1369,
          "minimum": 207.4253,
          "maximum": 993.4833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 914.0046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .315\\\" NAR 200138107S",
      "code_information": [
        {
          "code": "3599664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .50\\\" WIDE 200138108S",
      "code_information": [
        {
          "code": "3599666",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 19559.7053,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-BONE SCREW IB200051",
      "code_information": [
        {
          "code": "3599670",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1584,
          "minimum": 541.5139,
          "maximum": 4065.6471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1057.5481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDES-PT SPECIFIC PROPINF",
      "code_information": [
        {
          "code": "3599671",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7311,
          "minimum": 311.9721,
          "maximum": 5305.5927,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4881.1453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 2.4MM 200072",
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        {
          "code": "3599672",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 1123.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 374.5483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CORNER 4.8MM 33600048",
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        {
          "code": "3599673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2020,
          "minimum": 272.489,
          "maximum": 1465.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1348.6409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACID-5% ACETIC 9045052",
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        {
          "code": "3599696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 55.8789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL CARE DUOCARE MDS604DC",
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        {
          "code": "3599708",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 270.2646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3599751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 44.0645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-INTERSEPT 6031",
      "code_information": [
        {
          "code": "3599752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X1/4X1/4 Y 6036",
      "code_information": [
        {
          "code": "3599753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/2X3/8X3/8 6040",
      "code_information": [
        {
          "code": "3599754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.0645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PERFUSE 1/4\\\" 10007",
      "code_information": [
        {
          "code": "3599756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 3111.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/M P01-900-1703",
      "code_information": [
        {
          "code": "3599770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 870.8526,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1805.977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH 82-1516",
      "code_information": [
        {
          "code": "3599774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1505,
          "minimum": 514.5066,
          "maximum": 1092.1785,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1004.8042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOPRO-VASOVIEW 2 VEIN",
      "code_information": [
        {
          "code": "3599778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6789,
          "minimum": 43.9319,
          "maximum": 4926.7773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4532.6351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 5F 20\\\"",
      "code_information": [
        {
          "code": "3599779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 57.3303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 6.5F 36\\\"",
      "code_information": [
        {
          "code": "3599780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 392.0505,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.7439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UNIVERSAL PALM MEDIUM",
      "code_information": [
        {
          "code": "3599787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 128.4591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 17GX4.5\\\"",
      "code_information": [
        {
          "code": "3599788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 54.4978,
          "maximum": 167.6367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 154.2258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPACER IN-LINE 42-RTC24-VP",
      "code_information": [
        {
          "code": "3599789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 73.9613,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 65.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRIMARY DUOVENT 1424828",
      "code_information": [
        {
          "code": "3599790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 96.5181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-PED ANES W/FILTER",
      "code_information": [
        {
          "code": "3599791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 143,
          "minimum": 48.8867,
          "maximum": 2287.2393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 95.4731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 45MM",
      "code_information": [
        {
          "code": "3599808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2874,
          "minimum": 982.5196,
          "maximum": 2085.6618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1918.8089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 60MM",
      "code_information": [
        {
          "code": "3599809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3133,
          "minimum": 865.2916,
          "maximum": 2273.6181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2091.7287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 368,
          "minimum": 125.8063,
          "maximum": 267.0576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 245.693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 248.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 10CM SHORT",
      "code_information": [
        {
          "code": "3599881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.1173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 8CM SHORT",
      "code_information": [
        {
          "code": "3599882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 1067.712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "COIL-LP 2MMX4CM RBYLP0204",
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        {
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        {
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          "minimum": 870.8526,
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              "payer_name": "Anthem",
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      "service_type": "CDM"
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      "description": "BIT-1.1X70 KWIRE 03.130.200",
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        {
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          "minimum": 353.8301,
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              "payer_name": "Anthem",
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        {
          "setting": "inpatient",
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          "minimum": 378.7863,
          "maximum": 2659.8263,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "TUBE-GASTRO MIC-KEY G 18FR 2.7",
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        {
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              "payer_name": "Anthem",
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            }
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        }
      ],
      "service_type": "CDM"
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    {
      "description": "FORCEP-GRASPING DISP FG-600U",
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        {
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        {
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      "service_type": "CDM"
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    {
      "description": "CANNULA-AORTIC ROOT 10012",
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        {
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          "minimum": 77.6033,
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              "payer_name": "Anthem",
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        }
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      "service_type": "CDM"
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    {
      "description": "TUBE-LARY 9/36 7413",
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      "standard_charges": [
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PROVOX XTRAFLOW HME",
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          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 22.9049,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "TUBE-LARY 10/36",
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        {
          "code": "0270",
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      "standard_charges": [
        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
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        }
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      "service_type": "CDM"
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    {
      "description": "SET-THORA/PARA 6FRTAPS-6F-12PT",
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.3CM",
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNOTOMY 046-367",
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        {
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        {
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER SM 4934-8-100",
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        {
          "code": "0270",
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "HEMOCON-SH14 050179",
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        {
          "code": "0270",
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "CANNULA-AORTIC ROOT R501-26",
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        {
          "code": "0270",
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      ],
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        {
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          "minimum": 112.8154,
          "maximum": 239.481,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL XS EVF1XSLA",
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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      ],
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        {
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          ]
        }
      ],
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    {
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        {
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      ],
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            }
          ]
        }
      ],
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    {
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        {
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      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "BIT-DRILL 2X285MM 703583",
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        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        {
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      ],
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            }
          ]
        }
      ],
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    },
    {
      "description": "CANNULA-AORTIC ROOT AR-11114",
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        },
        {
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        }
      ],
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
      "description": "KIT-NANO 125MM AR-3210-0051",
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        },
        {
          "code": "0270",
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      ],
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        {
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          "minimum": 231.8937,
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "IRRIGATOR,SUCTION 8MM 480299",
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        {
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        }
      ],
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        {
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          "minimum": 638.6036,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-2.3MM INLINE DRILL MOUTH",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 842.0132,
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          "payers_information": [
            {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SPIRAL 7000AAO",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 22.9049,
          "maximum": 260.2548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ONESTEP 5F OSC-5F-12PT/C",
      "code_information": [
        {
          "code": "3600311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 468,
          "minimum": 159.9928,
          "maximum": 7277.6807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 312.4574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NASAL ETOC2 ADT",
      "code_information": [
        {
          "code": "3600315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 277,
          "minimum": 94.6966,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.9374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48MM EZOUT 7812-048-001K",
      "code_information": [
        {
          "code": "3600316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3389.6286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-50MM EZOUT 7812-050-001K",
      "code_information": [
        {
          "code": "3600317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 210.2058,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3389.6286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC/SAG 5.5 2296-023-412",
      "code_information": [
        {
          "code": "3600318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 1450.8649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 252.3694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FAT TRANS VIALITY-1400",
      "code_information": [
        {
          "code": "3600331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1097.1853,
          "maximum": 2456.4945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2259.9749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3600343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 2223.2878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL 3.5/2.5 AR-8943-14",
      "code_information": [
        {
          "code": "3600344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3998,
          "minimum": 232.4498,
          "maximum": 2901.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2669.2407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 MONOTEX T8623",
      "code_information": [
        {
          "code": "3600351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 199.6256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-VISION SUCTION PROBE",
      "code_information": [
        {
          "code": "3600353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 182.9569,
          "maximum": 433.2429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-VISION PROBE ION 490127",
      "code_information": [
        {
          "code": "3600354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 219.6549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 19G BIOPSY",
      "code_information": [
        {
          "code": "3600355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 21G BIOPSY",
      "code_information": [
        {
          "code": "3600356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 23G BIOPSY",
      "code_information": [
        {
          "code": "3600357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 98.9858,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 14-16FR",
      "code_information": [
        {
          "code": "3600358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 178,
          "minimum": 60.8519,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 118.8406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-ION SWIVEL",
      "code_information": [
        {
          "code": "3600359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 22602.1284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 906.6606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 5X356/126MM 03.008.008",
      "code_information": [
        {
          "code": "3600375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1921,
          "minimum": 580.0123,
          "maximum": 1394.0697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1282.5441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROC 2.3X230 P99-194-2323",
      "code_information": [
        {
          "code": "3600390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 958.1603,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.6469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3600412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 909.3311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUMIDIFIER-CPAP HC325S",
      "code_information": [
        {
          "code": "3600428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 444.88,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE M001141006",
      "code_information": [
        {
          "code": "3600430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1293,
          "minimum": 442.0313,
          "maximum": 3176.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 863.2637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-2-2.7MM 706200",
      "code_information": [
        {
          "code": "3600436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 941.378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-8MM/SD LORD 1088-43-008",
      "code_information": [
        {
          "code": "3600449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2636.5262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER FLX 4150016000",
      "code_information": [
        {
          "code": "3600467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4998,
          "minimum": 1708.6406,
          "maximum": 9651.6716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3336.8847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-9X250 STP 4150002090",
      "code_information": [
        {
          "code": "3600471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 10446.8946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1452.1257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-FETAL C-SECTION",
      "code_information": [
        {
          "code": "3600474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5613,
          "minimum": 546.0902,
          "maximum": 4073.3541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3747.4858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-BAND POLY CFI-733",
      "code_information": [
        {
          "code": "3600493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 1676.0854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.0762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PUMP 8\\\" AR-6411",
      "code_information": [
        {
          "code": "3600498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 261.5266,
          "maximum": 555.1605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 510.7477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC OUTFLOW AR-6435",
      "code_information": [
        {
          "code": "3600499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 752,
          "minimum": 257.0824,
          "maximum": 2799.9635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 502.0683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY M00516071",
      "code_information": [
        {
          "code": "3600502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 820.8036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.8758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VEIN HARVEST VASOVIEW",
      "code_information": [
        {
          "code": "3600503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1476,
          "minimum": 207.4253,
          "maximum": 1071.1332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 985.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURSPLEX DART300 NASAL",
      "code_information": [
        {
          "code": "3600506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 77.854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.0762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURAPLEX DART-REACH600",
      "code_information": [
        {
          "code": "3600507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.4702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY O40-403",
      "code_information": [
        {
          "code": "3600508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 4.6X340 P99-110-4634",
      "code_information": [
        {
          "code": "3600519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 207.4253,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1868.7356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 11X200 4922-8-200",
      "code_information": [
        {
          "code": "3600545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1786,
          "minimum": 610.5706,
          "maximum": 1296.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1192.4122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HEMOCON PERF 020271801",
      "code_information": [
        {
          "code": "3600548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 842,
          "minimum": 287.8502,
          "maximum": 5717.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 562.1562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-SINGLE NEOPRENE M8138",
      "code_information": [
        {
          "code": "3600550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 47.2685,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION ADULT",
      "code_information": [
        {
          "code": "3600551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 61.6845,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION PED",
      "code_information": [
        {
          "code": "3600552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 68.4003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383592",
      "code_information": [
        {
          "code": "3600553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 82.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG STRT AR-7821",
      "code_information": [
        {
          "code": "3600561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1108.9567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 10FL AR-9280NOT",
      "code_information": [
        {
          "code": "3600562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 378.7863,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 739.7496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-NANO 2.8X11 AR-9280NSR",
      "code_information": [
        {
          "code": "3600563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 378.7863,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 739.7496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-HP EVAC 70 E1CA5874-01",
      "code_information": [
        {
          "code": "3600565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2197,
          "minimum": 751.0771,
          "maximum": 1594.3629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1466.8139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-EVAC 70 EICA5872-01",
      "code_information": [
        {
          "code": "3600567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2097,
          "minimum": 716.8906,
          "maximum": 1521.7929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1400.0495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE XP EICA8872-01",
      "code_information": [
        {
          "code": "3600568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2093,
          "minimum": 715.5232,
          "maximum": 8030.6401,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1397.3789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PURPLE",
      "code_information": [
        {
          "code": "3600570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY PURPLE",
      "code_information": [
        {
          "code": "3600571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PINK/RED",
      "code_information": [
        {
          "code": "3600574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY YELLOW",
      "code_information": [
        {
          "code": "3600575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 173.4423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY WHITE",
      "code_information": [
        {
          "code": "3600576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION WHITE",
      "code_information": [
        {
          "code": "3600577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION BLUE",
      "code_information": [
        {
          "code": "3600579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION ORANGE",
      "code_information": [
        {
          "code": "3600580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY ORANGE",
      "code_information": [
        {
          "code": "3600581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION GREEN",
      "code_information": [
        {
          "code": "3600582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 455.4459,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GUIDE 95CM/9FR STRT",
      "code_information": [
        {
          "code": "3600599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1272.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 16MM P45-914-0001",
      "code_information": [
        {
          "code": "3600607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-XL 10MM HEX P45-941-0001",
      "code_information": [
        {
          "code": "3600609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 454.6656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT P45-170-1000",
      "code_information": [
        {
          "code": "3600610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 870.8526,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4510.6029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MEASURE STOMA MIC-KEY",
      "code_information": [
        {
          "code": "3600617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENTERAL FEEDING LITE",
      "code_information": [
        {
          "code": "3600618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.1349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-FARREL ENTERAL W BAG",
      "code_information": [
        {
          "code": "3600619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 786.8815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 84.1231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.7MM AR-7511",
      "code_information": [
        {
          "code": "3600664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 901.4381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 WHITE 48360W",
      "code_information": [
        {
          "code": "3600665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1082.2509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLUE 48360B",
      "code_information": [
        {
          "code": "3600666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1082.2509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 GREEN 48360G",
      "code_information": [
        {
          "code": "3600667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1082.2509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLACK 48360T",
      "code_information": [
        {
          "code": "3600668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1082.2509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-PORTABLE DEVILBISS",
      "code_information": [
        {
          "code": "3600669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2011,
          "minimum": 32.2538,
          "maximum": 1459.3827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1342.6321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WATER-STERILE INHALATION 500ML",
      "code_information": [
        {
          "code": "3600670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 1121.0976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-14FR SU130-1239",
      "code_information": [
        {
          "code": "3600671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2016,
          "minimum": 689.1996,
          "maximum": 1463.0112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1345.9703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-16FR SU130-1240",
      "code_information": [
        {
          "code": "3600672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2016,
          "minimum": 689.1996,
          "maximum": 6323.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1345.9703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-12mm 47050",
      "code_information": [
        {
          "code": "3600674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 333.66,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 199.6256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X185MM 2351-4218S",
      "code_information": [
        {
          "code": "3600681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 867.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 1.7MM DSDS0017",
      "code_information": [
        {
          "code": "3600688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1272.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2MM DSDS0020",
      "code_information": [
        {
          "code": "3600689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 272.489,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1272.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3600708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1042,
          "minimum": 356.2232,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 695.685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.6X150MM AR-8741-16",
      "code_information": [
        {
          "code": "3600710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 209.905,
          "maximum": 1371.8987,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 409.9334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,-TR 2X8MM AR-300-B002",
      "code_information": [
        {
          "code": "3600711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 1790.3019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1647.0777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION AR-200",
      "code_information": [
        {
          "code": "3600717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 263.0517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-3.7MM DRILL AR-2272",
      "code_information": [
        {
          "code": "3600719",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1425,
          "minimum": 487.1574,
          "maximum": 4598.3909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 951.3927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO POLY M-L 51114V",
      "code_information": [
        {
          "code": "3600722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 93.4248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 52.0762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.102",
      "code_information": [
        {
          "code": "3600736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 25181.3202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 X806H",
      "code_information": [
        {
          "code": "3600739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 4854.1969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.0938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN PVC 24FR",
      "code_information": [
        {
          "code": "3600749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 746.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 46.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANCHOR-ENTUIT SUTURE G35562",
      "code_information": [
        {
          "code": "3600750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1342,
          "minimum": 431.5336,
          "maximum": 973.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 895.9782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LEAD-CATH 4FR 38 383069",
      "code_information": [
        {
          "code": "3600757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 23820.5435,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1769.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-NITINOL 2.0MM",
      "code_information": [
        {
          "code": "3600759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6MM MXM-072-16",
      "code_information": [
        {
          "code": "3600767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1201.0916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6 MXM-072-ISO-16",
      "code_information": [
        {
          "code": "3600768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1201.0916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RCC RMH-T015S",
      "code_information": [
        {
          "code": "3600773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 904,
          "minimum": 309.0458,
          "maximum": 3144.7455,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 603.5502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXOFIN FUSION EF70430",
      "code_information": [
        {
          "code": "3600781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 976,
          "minimum": 62.2832,
          "maximum": 708.2832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 651.6205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 MONOTEX FS-2 T8665",
      "code_information": [
        {
          "code": "3600782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 300.294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 74.7761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA",
      "code_information": [
        {
          "code": "3600783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 360.5278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "XTRAFLANGE-PROVOX 20 FR 7276",
      "code_information": [
        {
          "code": "3600784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 1084.9511,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 360.5278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20 FR 6MM 8277",
      "code_information": [
        {
          "code": "3600785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1951,
          "minimum": 666.9783,
          "maximum": 1622.6998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1302.5734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2006-NS",
      "code_information": [
        {
          "code": "3600786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1948.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-NS",
      "code_information": [
        {
          "code": "3600787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1948.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7FR 4",
      "code_information": [
        {
          "code": "3600789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7F 34",
      "code_information": [
        {
          "code": "3600790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 722.93,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE 4.2X130 2351-4213S",
      "code_information": [
        {
          "code": "3600791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 867.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-LOCK 4.2X360 2351-4236S",
      "code_information": [
        {
          "code": "3600792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 867.9372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-CARDIOTOMY EL400",
      "code_information": [
        {
          "code": "3600858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 579,
          "minimum": 197.9398,
          "maximum": 670.6566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 386.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 34CC LINEAR",
      "code_information": [
        {
          "code": "3600866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4523,
          "minimum": 1546.2548,
          "maximum": 3282.3411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3019.7538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 40CC MEGA 0",
      "code_information": [
        {
          "code": "3600867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4905,
          "minimum": 1676.8471,
          "maximum": 3559.5585,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3274.7938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 50CC MEGA 0",
      "code_information": [
        {
          "code": "3600868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4905,
          "minimum": 1676.8471,
          "maximum": 3559.5585,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3274.7938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-8\\\" THD AR-8967KT",
      "code_information": [
        {
          "code": "3600879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 836.3744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.04,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1 LMA",
      "code_information": [
        {
          "code": "3600899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-STR 4MM P1-AU511",
      "code_information": [
        {
          "code": "3600906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7067,
          "minimum": 45.6002,
          "maximum": 5128.5219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4718.2401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1.5 LMA",
      "code_information": [
        {
          "code": "3600907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 59.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 3 LMA",
      "code_information": [
        {
          "code": "3600908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 5 LMA",
      "code_information": [
        {
          "code": "3600909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 2 LMA",
      "code_information": [
        {
          "code": "3600910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS MED TRACTION",
      "code_information": [
        {
          "code": "3600912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS LG TRACTION",
      "code_information": [
        {
          "code": "3600913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS SM TRACTION",
      "code_information": [
        {
          "code": "3600914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 64.5076,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 184.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 130187",
      "code_information": [
        {
          "code": "3600915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 6163.2563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 77.4467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SHRT SCREW 6149.1042",
      "code_information": [
        {
          "code": "3600925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EZX 54MM BRXTB540",
      "code_information": [
        {
          "code": "3600938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5636,
          "minimum": 1926.7504,
          "maximum": 6657.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3762.8416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX 45MM 227445500",
      "code_information": [
        {
          "code": "3600946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1795.0908,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-TOGA XL 0416-830-100",
      "code_information": [
        {
          "code": "3600948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 909,
          "minimum": 310.7552,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 606.8884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20F 10MM 8279",
      "code_information": [
        {
          "code": "3600952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1894,
          "minimum": 647.492,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1264.5177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS MALLEABLE 4MM",
      "code_information": [
        {
          "code": "3600954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 9196.7818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1452.1257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG LIGHT MED C02051",
      "code_information": [
        {
          "code": "3600964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 79.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 73.4408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG SMALL C020500",
      "code_information": [
        {
          "code": "3600965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 1673.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 228MM 56010228",
      "code_information": [
        {
          "code": "3600977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-JONES 3.2MM 56013200",
      "code_information": [
        {
          "code": "3600978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1272.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 5.5MM 56015500",
      "code_information": [
        {
          "code": "3600980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1584,
          "minimum": 541.5139,
          "maximum": 4020.603,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1057.5481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CRYOTHERAPY FGS-7000",
      "code_information": [
        {
          "code": "3600997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5867,
          "minimum": 75.0735,
          "maximum": 4257.6819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3917.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXHAUST COLLECT FGS-7015",
      "code_information": [
        {
          "code": "3600999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONN-X 5.5/32-40 LNG 1119.0034",
      "code_information": [
        {
          "code": "3601000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 1089.8652,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2128.4491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PREP 4.2MM 0909-100-042",
      "code_information": [
        {
          "code": "3601029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EXP 4.2MM 0909-200-042",
      "code_information": [
        {
          "code": "3601030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 389.27,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ XF 4.2MM 0909-400-400",
      "code_information": [
        {
          "code": "3601031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 700,
          "minimum": 239.3054,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 467.3508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 10MM 650.110",
      "code_information": [
        {
          "code": "3601032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CRV 4MM P1-AU550",
      "code_information": [
        {
          "code": "3601055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 2690.4764,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5254.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-360-430 ALLOX2-FH13SE",
      "code_information": [
        {
          "code": "3601056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7446,
          "minimum": 207.4253,
          "maximum": 5403.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4971.2772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACENTESIS/PARACENTESI",
      "code_information": [
        {
          "code": "3601066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 701,
          "minimum": 226.3327,
          "maximum": 508.7157,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 468.0184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G CMNT 0306-150-000",
      "code_information": [
        {
          "code": "3601086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 598,
          "minimum": 204.4352,
          "maximum": 433.9686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 399.2511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CMNT 11G 0306-330-000",
      "code_information": [
        {
          "code": "3601087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 642,
          "minimum": 219.4772,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 428.6274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TB AR-200",
      "code_information": [
        {
          "code": "3601096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 271.0635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRILL 3X320 P31-951-3032",
      "code_information": [
        {
          "code": "3601107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1963,
          "minimum": 671.0807,
          "maximum": 1556.5239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1310.5852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 7X200 P99-110-7019",
      "code_information": [
        {
          "code": "3601108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1868.7356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-110-4630",
      "code_information": [
        {
          "code": "3601109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1868.7356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.8X250 P99-100-3825",
      "code_information": [
        {
          "code": "3601110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1868.7356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-16 HLW 03.037.004S",
      "code_information": [
        {
          "code": "3601121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CENTRAL VENOUS PED",
      "code_information": [
        {
          "code": "3601123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 669,
          "minimum": 194.635,
          "maximum": 485.4933,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 446.6538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOD-PROTECTOR 69392",
      "code_information": [
        {
          "code": "3601124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 350,
          "minimum": 119.6527,
          "maximum": 253.995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.6754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT ADULT DISP 731",
      "code_information": [
        {
          "code": "3601125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 273,
          "minimum": 93.3291,
          "maximum": 198.1161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.2668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-VARISPEED 62-50201",
      "code_information": [
        {
          "code": "3601154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1913,
          "minimum": 653.9875,
          "maximum": 1388.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1277.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.5MM 72202189",
      "code_information": [
        {
          "code": "3601200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1735.5881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STR 14MM/SC 684.424",
      "code_information": [
        {
          "code": "3601216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2509.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SUCTION BALLARD 14FR",
      "code_information": [
        {
          "code": "3601234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 952.0432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.1319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 35FR 412351000",
      "code_information": [
        {
          "code": "3601235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1143.0065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 37FR 412371000",
      "code_information": [
        {
          "code": "3601236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1165.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 39FR 412391000",
      "code_information": [
        {
          "code": "3601237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1165.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER MD 4934-8-140",
      "code_information": [
        {
          "code": "3601242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-1.8X450 DIA PT 4933-8-010",
      "code_information": [
        {
          "code": "3601244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 682,
          "minimum": 233.1518,
          "maximum": 494.9274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 455.3332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 120MM 4933-1-120",
      "code_information": [
        {
          "code": "3601245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 527,
          "minimum": 180.1628,
          "maximum": 382.4439,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 351.8484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SCREW 6149.1040",
      "code_information": [
        {
          "code": "3601255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 42686.7921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-IV SW 3000ML BAG S8505",
      "code_information": [
        {
          "code": "3601260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 22040.4674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4MM CANN AR-8973-40S",
      "code_information": [
        {
          "code": "3601272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1042.8599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-PIN & PROT P45-610-1000",
      "code_information": [
        {
          "code": "3601289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 1074.9413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 277.0723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-10MM P47-950-0001",
      "code_information": [
        {
          "code": "3601290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1933,
          "minimum": 115.6688,
          "maximum": 1402.7781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1290.5559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-PROTECT P45-600-1000-S",
      "code_information": [
        {
          "code": "3601291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.87,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-AIR+MENISCAL CV 4722",
      "code_information": [
        {
          "code": "3601324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 870.8526,
          "maximum": 1851.2607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1703.1598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-GRAFT LG M00236320021",
      "code_information": [
        {
          "code": "3601349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 176,
          "minimum": 60.1682,
          "maximum": 157.3763,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 117.5053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC SMALL 313-9013W",
      "code_information": [
        {
          "code": "3601350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.9433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC MED 313-9014W",
      "code_information": [
        {
          "code": "3601351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.9433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-2.5 PRCSN MTCH HD 16CM",
      "code_information": [
        {
          "code": "3601354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1891,
          "minimum": 646.4665,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1262.5148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROCH 1.1MM AR-18700-30",
      "code_information": [
        {
          "code": "3601375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STEP SOLID 1806-3026S",
      "code_information": [
        {
          "code": "3601387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1432,
          "minimum": 489.5505,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 956.0662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47522",
      "code_information": [
        {
          "code": "3601390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 909.3021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 836.5579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOCLOT EPK2303-01",
      "code_information": [
        {
          "code": "3601392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 329.2112,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-ENDOCLOT EA230",
      "code_information": [
        {
          "code": "3601393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 592,
          "minimum": 202.384,
          "maximum": 11794.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 395.2452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 12\\\" 3.2MM",
      "code_information": [
        {
          "code": "3601397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 399,
          "minimum": 136.4041,
          "maximum": 5711.147,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 266.39,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.25MM  AR-18800-35",
      "code_information": [
        {
          "code": "3601403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 851,
          "minimum": 290.927,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 568.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-10X16X8/12° 1213.6088S",
      "code_information": [
        {
          "code": "3601406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6769,
          "minimum": 2314.0832,
          "maximum": 4912.2633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4519.2822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 16X8MM 1128.2408",
      "code_information": [
        {
          "code": "3601407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 580.5684,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3013.0774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X14MM 184.014",
      "code_information": [
        {
          "code": "3601408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X16MM 184.016",
      "code_information": [
        {
          "code": "3601409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR SD 4.2X14MM 184.054",
      "code_information": [
        {
          "code": "3601410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI REFLUX",
      "code_information": [
        {
          "code": "3601418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 47.4027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-KANGAROO Y-PORT/PEG",
      "code_information": [
        {
          "code": "3601419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 58.056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 53.4115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 18FR 8887605189",
      "code_information": [
        {
          "code": "3601420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 20FR 8887605205",
      "code_information": [
        {
          "code": "3601421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 3586.2889,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IN/OUTFLOW AR-6436",
      "code_information": [
        {
          "code": "3601433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1031,
          "minimum": 352.4627,
          "maximum": 748.1967,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 688.341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 53.9417,
          "maximum": 445.5798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 409.9334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G-TUBE ENFIT",
      "code_information": [
        {
          "code": "3601440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1234,
          "minimum": 392.6066,
          "maximum": 895.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 823.8727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG ENFIT 24FR M00509061",
      "code_information": [
        {
          "code": "3601441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 471.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5020",
      "code_information": [
        {
          "code": "3601445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 846,
          "minimum": 60.0588,
          "maximum": 613.9422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 564.8268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOCKWAVE STERILE CABLE",
      "code_information": [
        {
          "code": "3601446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 84.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16FR 20CM G01212",
      "code_information": [
        {
          "code": "3601447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-18FR 20CM G01328",
      "code_information": [
        {
          "code": "3601448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO JEJUNAL 8250-22",
      "code_information": [
        {
          "code": "3601452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1577,
          "minimum": 539.1209,
          "maximum": 1144.4289,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1052.8746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 8200-20",
      "code_information": [
        {
          "code": "3601453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 246.9084,
          "maximum": 1004.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 924.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10FR 50-7361",
      "code_information": [
        {
          "code": "3601454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 444,
          "minimum": 151.788,
          "maximum": 544.978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 296.4339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 18140",
      "code_information": [
        {
          "code": "3601455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 711.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.2911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DLP CORONARY 30315",
      "code_information": [
        {
          "code": "3601479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 510,
          "minimum": 174.3511,
          "maximum": 486.5875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 340.4984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 875,
          "minimum": 53.9417,
          "maximum": 634.9875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 584.1885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 14FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.7615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.7615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC DRG MN12050",
      "code_information": [
        {
          "code": "3601484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 42051.7259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1792.6241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PREFORM-S3-4 39+6MM DWP2396",
      "code_information": [
        {
          "code": "3601576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8123,
          "minimum": 2509.6793,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5423.2722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 18X7MM 1128.1507",
      "code_information": [
        {
          "code": "3601577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 1542.8361,
          "maximum": 17566.6429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3013.0774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-20X55 8-17 5° 1122.1055",
      "code_information": [
        {
          "code": "3601578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 31589,
          "minimum": 870.8526,
          "maximum": 22924.1373,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 21090.2063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 3X14 AR-8630-14",
      "code_information": [
        {
          "code": "3601580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 2.5X16 AR-8625-16",
      "code_information": [
        {
          "code": "3601581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 670.6566,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LP/CRT 1.6X9 AR-18716-09",
      "code_information": [
        {
          "code": "3601582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1206,
          "minimum": 230.7815,
          "maximum": 875.1942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 805.1787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CABLE PLATE 94-1200-08",
      "code_information": [
        {
          "code": "3601588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5867,
          "minimum": 2005.7211,
          "maximum": 4257.6819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3917.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AUX CBL PLT 94-1500-04-S",
      "code_information": [
        {
          "code": "3601589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 534.4121,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1195",
      "code_information": [
        {
          "code": "3601590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 836.3744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 641.6059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ1 CN P2ND1001",
      "code_information": [
        {
          "code": "3601591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 514.1647,
          "maximum": 4843.631,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1004.1366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-PEDI DSG P2HE2000",
      "code_information": [
        {
          "code": "3601592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8710,
          "minimum": 870.8526,
          "maximum": 6320.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5815.1792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BALLARD/NEO BAA2103",
      "code_information": [
        {
          "code": "3601615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-DF 65MM/RT/STD 6495-2-040",
      "code_information": [
        {
          "code": "3601630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21681,
          "minimum": 1548.1824,
          "maximum": 15733.9017,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14475.1896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CN/CC 7X45MM 8040-045",
      "code_information": [
        {
          "code": "3601631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 497.7095,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1858.7209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-SMALL KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7523,
          "minimum": 2571.8493,
          "maximum": 5459.4411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5022.6858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-LARGE KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7523,
          "minimum": 1795.0908,
          "maximum": 5459.4411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5022.6858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-WOUND CROWN",
      "code_information": [
        {
          "code": "3601647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 571.8516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 526.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN RAL 6MM B02236010",
      "code_information": [
        {
          "code": "3601652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 1826.5869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1680.4599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN STD 6MM B02236001",
      "code_information": [
        {
          "code": "3601653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 7992.8253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1680.4599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL LK 3.5 AR-8943-43",
      "code_information": [
        {
          "code": "3601667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 2352.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1787.9506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ALEXIS M/L HR105",
      "code_information": [
        {
          "code": "3601692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1165.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5 SHORT 6149.1038S",
      "code_information": [
        {
          "code": "3601700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLEY-COUVEL 3-W",
      "code_information": [
        {
          "code": "3601705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 99.5419,
          "maximum": 216.9843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 199.6256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-O3 OXIMETRY CEREBRAL",
      "code_information": [
        {
          "code": "3601707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM",
      "code_information": [
        {
          "code": "3601709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 929.1887,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1814.6564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM BOX",
      "code_information": [
        {
          "code": "3601710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2537,
          "minimum": 165.7178,
          "maximum": 1841.1009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1693.8128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 23/M P01-900-2303",
      "code_information": [
        {
          "code": "3601722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 4555.0151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1805.977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ2 CN P2ND1002",
      "code_information": [
        {
          "code": "3601743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 514.1647,
          "maximum": 1091.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1004.1366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 16FR",
      "code_information": [
        {
          "code": "3601752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 2180.4681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 654.2911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-DEBRIDEMENT DDBK02",
      "code_information": [
        {
          "code": "3601755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4392.0778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CV/XS 4MM P1-AU551",
      "code_information": [
        {
          "code": "3601759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 2690.4764,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5254.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 3/10F AR-98300OBT",
      "code_information": [
        {
          "code": "3601764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 827,
          "minimum": 282.7222,
          "maximum": 600.1539,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 552.1416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CIR/BEV P45-940-1001",
      "code_information": [
        {
          "code": "3601766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 5151.7104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FLIPCUTTER III AR-1204FF",
      "code_information": [
        {
          "code": "3601777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2543,
          "minimum": 869.3623,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1697.8187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MGS 3MM AR-9628S",
      "code_information": [
        {
          "code": "3601781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-INFANT NEONATE CO2",
      "code_information": [
        {
          "code": "3601783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.5317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCAN 4MM AR-1204D",
      "code_information": [
        {
          "code": "3601799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1261,
          "minimum": 431.0916,
          "maximum": 1371.8987,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 841.8991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-.066CN 2.75MM AR-7000-14",
      "code_information": [
        {
          "code": "3601800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 1790.3019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1647.0777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X6\\\" AR-8941-6",
      "code_information": [
        {
          "code": "3601803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X7\\\" AR-8941-7",
      "code_information": [
        {
          "code": "3601804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 923.6821,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG ST TR AR-7823",
      "code_information": [
        {
          "code": "3601805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1108.9567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JTIP 8164-2001-25",
      "code_information": [
        {
          "code": "3601822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.7409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRAY AR-200SP",
      "code_information": [
        {
          "code": "3601873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1980,
          "minimum": 676.8924,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1321.9351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G MIS SHARP 501168",
      "code_information": [
        {
          "code": "3601880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 2801.6318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE 6MM BH-220",
      "code_information": [
        {
          "code": "3601882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11846,
          "minimum": 1735.5881,
          "maximum": 8596.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7908.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMAN.157X9\\\" KI71675",
      "code_information": [
        {
          "code": "3601893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 193,
          "minimum": 31.6977,
          "maximum": 140.0601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 128.8553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .035X9\\\" DD KI71211",
      "code_information": [
        {
          "code": "3601894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 7509.5744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.0557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FRACTURE KEX152EB",
      "code_information": [
        {
          "code": "3601895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 13504,
          "minimum": 870.8526,
          "maximum": 9799.8528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9015.8646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-TIB 11X360MM 1822-1136S",
      "code_information": [
        {
          "code": "3601898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5142,
          "minimum": 1757.8691,
          "maximum": 10766.096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3433.0254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LASER TRACH #5 102004050",
      "code_information": [
        {
          "code": "3601900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1245,
          "minimum": 425.6218,
          "maximum": 1157.2441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 831.2168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-BLOOD COLLECT 04258",
      "code_information": [
        {
          "code": "3601933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 424.5345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 390.5717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77720",
      "code_information": [
        {
          "code": "3601934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 744,
          "minimum": 254.3475,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 496.7271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .062X5\\\" 5050-249",
      "code_information": [
        {
          "code": "3601939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 143,
          "minimum": 48.8867,
          "maximum": 103.7751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 95.4731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLUTION-WOUND VASHE 16OZ 003",
      "code_information": [
        {
          "code": "3601945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 24996.1389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 208.3049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX944",
      "code_information": [
        {
          "code": "3601947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 278,
          "minimum": 95.0384,
          "maximum": 7214.8414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 185.605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM AO 702473",
      "code_information": [
        {
          "code": "3601950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2131,
          "minimum": 728.514,
          "maximum": 1546.4667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1422.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-7MM P20-910-7000",
      "code_information": [
        {
          "code": "3601961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 1746.7101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1150.3506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 400MM BT 693.060S",
      "code_information": [
        {
          "code": "3601978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 525,
          "minimum": 179.4791,
          "maximum": 1399.7037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 350.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM 1032-115-000",
      "code_information": [
        {
          "code": "3601985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10370,
          "minimum": 3545.1386,
          "maximum": 11179.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6923.4683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM 2PROBE 9700-020-200",
      "code_information": [
        {
          "code": "3601986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 20104,
          "minimum": 265.8158,
          "maximum": 14589.4728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 13422.315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-AEOS STERILE PV012SU",
      "code_information": [
        {
          "code": "3601989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 462,
          "minimum": 157.9416,
          "maximum": 335.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 308.4515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA 22FR 77422",
      "code_information": [
        {
          "code": "3601990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 191.1025,
          "maximum": 1175.5954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 373.213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ENDO 5MM 174209",
      "code_information": [
        {
          "code": "3601996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1819,
          "minimum": 464.8996,
          "maximum": 1320.0483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1214.4444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 6213-119-070",
      "code_information": [
        {
          "code": "3601997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 194.0789,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 558.1504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PURESOME TMD-07",
      "code_information": [
        {
          "code": "3601998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 349,
          "minimum": 99.5419,
          "maximum": 253.2693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 233.0078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM AR-8943-36",
      "code_information": [
        {
          "code": "3602028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1198,
          "minimum": 409.5541,
          "maximum": 869.3886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 799.8375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PED LUMBAR 21G 645",
      "code_information": [
        {
          "code": "3602032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN HEEL 10X10",
      "code_information": [
        {
          "code": "3602037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 142.3616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X C/D",
      "code_information": [
        {
          "code": "3602043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X C/D",
      "code_information": [
        {
          "code": "3602044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 209.0016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 192.2815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X C/D",
      "code_information": [
        {
          "code": "3602045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.6725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL C/D",
      "code_information": [
        {
          "code": "3602046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.6725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG C/D",
      "code_information": [
        {
          "code": "3602047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.6725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED C/D",
      "code_information": [
        {
          "code": "3602048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.6725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K SMALL C/D",
      "code_information": [
        {
          "code": "3602049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X A/B",
      "code_information": [
        {
          "code": "3602050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X A/B",
      "code_information": [
        {
          "code": "3602051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X A/B",
      "code_information": [
        {
          "code": "3602052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 209.0016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 192.2815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL A/B",
      "code_information": [
        {
          "code": "3602053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.6725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG A/B",
      "code_information": [
        {
          "code": "3602054",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.6725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN CMP 2.2 DSDS0022",
      "code_information": [
        {
          "code": "3602079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1272.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-JOINT PREP INST 9914PK01",
      "code_information": [
        {
          "code": "3602083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 418.1872,
          "maximum": 1704.6693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1568.2958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP 1.1 NT/SM 58820006",
      "code_information": [
        {
          "code": "3602084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 752,
          "minimum": 257.0824,
          "maximum": 1541.5092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 502.0683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MICA 2X12MM 57SR0212",
      "code_information": [
        {
          "code": "3602085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2772,
          "minimum": 947.6494,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1850.7092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MICA INST BLADE 57S1MI07",
      "code_information": [
        {
          "code": "3602088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2242,
          "minimum": 766.461,
          "maximum": 1627.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1496.8578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAMPATNCY FGS-0668",
      "code_information": [
        {
          "code": "3602103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.04,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRUDI SHAVER TSB4STR",
      "code_information": [
        {
          "code": "3602104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 497.7095,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2128.4491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-BIENAIR AQUACARE 1600617",
      "code_information": [
        {
          "code": "3602106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 145.1421,
          "maximum": 433.2429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-OSTOMY 18665",
      "code_information": [
        {
          "code": "3602109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-CLOSED TUBE 1320-0125S",
      "code_information": [
        {
          "code": "3602113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 959,
          "minimum": 327.8484,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 640.2706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 724G",
      "code_information": [
        {
          "code": "3602121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 52.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0 8756H",
      "code_information": [
        {
          "code": "3602122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 7.7854,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.7585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0   8717H",
      "code_information": [
        {
          "code": "3602124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 71.4498,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 139.5376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-EVARREST 2x4\\\" EVT5024",
      "code_information": [
        {
          "code": "3602126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4700,
          "minimum": 1606.7648,
          "maximum": 3410.79,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3137.9268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-6 LEAD ECG SNAP BR-916PA",
      "code_information": [
        {
          "code": "3602128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1080,
          "minimum": 369.214,
          "maximum": 783.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 721.0555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TRI 4.0MM P1-AU411",
      "code_information": [
        {
          "code": "3602153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7067,
          "minimum": 207.4253,
          "maximum": 5128.5219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4718.2401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1165.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 318.4662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 915.3399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1858.7209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 765.12,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 C012D",
      "code_information": [
        {
          "code": "3602196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 190.7423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 109.4936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1108.9567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 3788.7093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2689.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1165.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 318.4662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 915.3399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1858.7209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 765.12,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3164,
          "minimum": 1081.6604,
          "maximum": 2296.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2112.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 2923.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2689.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1108.9567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-END +5 HUM 1830-0005S",
      "code_information": [
        {
          "code": "3602288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1128,
          "minimum": 385.6236,
          "maximum": 1795.0908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 753.1024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1165.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 318.4662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 994.9347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 915.3399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2785,
          "minimum": 952.0936,
          "maximum": 2021.0745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1859.3885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 765.12,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT DL 15MM PROBE 9700-015-200",
      "code_information": [
        {
          "code": "3602331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 22350,
          "minimum": 870.8526,
          "maximum": 16219.395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14921.8434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 637.2906,
          "maximum": 2923.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2689.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3164,
          "minimum": 1081.6604,
          "maximum": 2296.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2112.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2185,
          "minimum": 746.9747,
          "maximum": 5893.5478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1458.8021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2689.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1108.9567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1165.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1010.4337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 318.4662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 915.3399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1858.7209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 765.12,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT 125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 3017.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5426,
          "minimum": 1854.9587,
          "maximum": 3937.6482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3622.6363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2185,
          "minimum": 746.9747,
          "maximum": 3017.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1458.8021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5426,
          "minimum": 580.5684,
          "maximum": 3937.6482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3622.6363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 13MM 7786713",
      "code_information": [
        {
          "code": "3602404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 7786703",
      "code_information": [
        {
          "code": "3602405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-MDI SPACER M 1082715",
      "code_information": [
        {
          "code": "3602410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 136.2445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.1026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRXPERION XP65/115VS",
      "code_information": [
        {
          "code": "3602411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 83.7569,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 163.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH SZ5/90MM A0A14",
      "code_information": [
        {
          "code": "3602422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 2737.1242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON LINEAR 40",
      "code_information": [
        {
          "code": "3602462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5202,
          "minimum": 99.5419,
          "maximum": 3775.0914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3473.0841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 111331",
      "code_information": [
        {
          "code": "3602483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 966,
          "minimum": 330.2415,
          "maximum": 1123.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 644.9441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SKIN CLOSURE CLR602US",
      "code_information": [
        {
          "code": "3602486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1556,
          "minimum": 531.9417,
          "maximum": 1129.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1038.8541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-RADIAN FACET K 5526061",
      "code_information": [
        {
          "code": "3602487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1514,
          "minimum": 517.5834,
          "maximum": 1098.7098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1010.813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 11MM 7786711",
      "code_information": [
        {
          "code": "3602491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PELVIC STAB T-PODR",
      "code_information": [
        {
          "code": "3602497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 319.6436,
          "maximum": 5019.3586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 624.2471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIR-G BL-NOSE 3X900 0101-900S",
      "code_information": [
        {
          "code": "3602503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 981.5165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 836.5579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165MM S0210-200",
      "code_information": [
        {
          "code": "3602508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1940,
          "minimum": 663.2178,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1295.2294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OPEN REAMER 03.168.004",
      "code_information": [
        {
          "code": "3602515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8067,
          "minimum": 1758.9443,
          "maximum": 5854.2219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5385.8841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3X413MM 03.168.011",
      "code_information": [
        {
          "code": "3602516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3163,
          "minimum": 1079.9462,
          "maximum": 2295.3891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2111.758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LOWER 8/+0 END 2330-0000S",
      "code_information": [
        {
          "code": "3602538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1299,
          "minimum": 444.0825,
          "maximum": 942.6843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 867.2696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEART LOOP AV 9S44R",
      "code_information": [
        {
          "code": "3602540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 525,
          "minimum": 179.4791,
          "maximum": 3726.9822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 350.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-LOW PROFILE 6143.2527",
      "code_information": [
        {
          "code": "3602541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6702,
          "minimum": 2249.4245,
          "maximum": 4863.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4474.5501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 160MM P45-180-0160",
      "code_information": [
        {
          "code": "3602542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4045,
          "minimum": 1382.8434,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2700.62,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 160MM P45-112-0140",
      "code_information": [
        {
          "code": "3602543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 1091.6243,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4510.6029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-G BALL 3X550 P31-955-1550",
      "code_information": [
        {
          "code": "3602544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1963,
          "minimum": 610.0417,
          "maximum": 1424.5491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1310.5852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-300MM THRED P45-310-0300",
      "code_information": [
        {
          "code": "3602545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 3455.6054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.4055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRUTS-QA MOD MD P45-224-0170",
      "code_information": [
        {
          "code": "3602546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6214,
          "minimum": 870.8526,
          "maximum": 4509.4998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4148.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KET-ENDO BSC CEK-924-20",
      "code_information": [
        {
          "code": "3602548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 13697.2991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.8817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INST ARAGONITE MINI-DS",
      "code_information": [
        {
          "code": "3602550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 13194.0286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1344.635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOINT-BALL MOD P45-233-1000",
      "code_information": [
        {
          "code": "3602557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2217.9134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE 1.8 P99-202-1810",
      "code_information": [
        {
          "code": "3602569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1065,
          "minimum": 207.4253,
          "maximum": 772.8705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 711.0409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCPP41D",
      "code_information": [
        {
          "code": "3602572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PRONE LAT STAB 6246.0200",
      "code_information": [
        {
          "code": "3602576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7446,
          "minimum": 2545.5257,
          "maximum": 5403.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4971.2772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TT 2.4X9.25 AR-8870K",
      "code_information": [
        {
          "code": "3602593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 235,
          "minimum": 80.3382,
          "maximum": 900.3259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 156.8963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT W/CAP",
      "code_information": [
        {
          "code": "3602596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT 205-212",
      "code_information": [
        {
          "code": "3602597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT WAVE+ 3.9M",
      "code_information": [
        {
          "code": "3602598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3201.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT FLEX 2.9MM",
      "code_information": [
        {
          "code": "3602599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 1542.8361,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3013.0774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT SMOL 2.9MM",
      "code_information": [
        {
          "code": "3602600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3012,
          "minimum": 870.8526,
          "maximum": 2185.8084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2010.9437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3602604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4897,
          "minimum": 1674.1122,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3269.4527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3602606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4897,
          "minimum": 1674.1122,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3269.4527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.2L CN AR-8973-32LS",
      "code_information": [
        {
          "code": "3602614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 4355.9313,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1042.8599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°RT AR-4068-90R",
      "code_information": [
        {
          "code": "3602617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 976.0955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°LT AR-4068-90L",
      "code_information": [
        {
          "code": "3602618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 524.7626,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1024.8335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°LT AR-4068-45L",
      "code_information": [
        {
          "code": "3602619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 524.7626,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1024.8335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°RT AR-4068-45R",
      "code_information": [
        {
          "code": "3602620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 222.9961,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1024.8335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPLEDAM AR-6530TD",
      "code_information": [
        {
          "code": "3602621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 267.7252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DTRAX SPINAL DX-22-300",
      "code_information": [
        {
          "code": "3602622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 870.8526,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3389.6286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS 11G/5\\\"\\\" 0306-116-000",
      "code_information": [
        {
          "code": "3602624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 774,
          "minimum": 264.6034,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 516.7565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-GUIDE VDR 80-0049",
      "code_information": [
        {
          "code": "3602651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1847.3642,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-OPTIFIX ABSORB 0113126",
      "code_information": [
        {
          "code": "3602652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2217.9134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 14FR G00996",
      "code_information": [
        {
          "code": "3602678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.8084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 12FR G00995",
      "code_information": [
        {
          "code": "3602679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 101.4819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-MWCE-18S-4/2-TORNADO",
      "code_information": [
        {
          "code": "3602685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1086,
          "minimum": 371.2652,
          "maximum": 788.1102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 725.0614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-10-8 MREYE",
      "code_information": [
        {
          "code": "3602686",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.2266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-8 MREYE G42423",
      "code_information": [
        {
          "code": "3602687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.2266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION MREYE G42414",
      "code_information": [
        {
          "code": "3602690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.2266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-5 MREYE G42410",
      "code_information": [
        {
          "code": "3602691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.2266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-4 MREYE G42409",
      "code_information": [
        {
          "code": "3602692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.2266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-3 MREYE G42408",
      "code_information": [
        {
          "code": "3602693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.2266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-2-3 MREYE G42406",
      "code_information": [
        {
          "code": "3602694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 7516.2476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 610.2266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 15MM X 15G",
      "code_information": [
        {
          "code": "3602699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1426,
          "minimum": 487.4993,
          "maximum": 1034.8482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 952.0603,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CO 2.10MM NS1806.002 STE",
      "code_information": [
        {
          "code": "3602710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1658,
          "minimum": 566.8119,
          "maximum": 5094.4321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1106.9538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2883-01-024",
      "code_information": [
        {
          "code": "3602763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1645,
          "minimum": 265.2597,
          "maximum": 1193.7765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1098.2744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC SAW 1.27MM 71440375",
      "code_information": [
        {
          "code": "3602770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 5079.4174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 494.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X340MM 1806-4260S",
      "code_information": [
        {
          "code": "3602772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1134,
          "minimum": 387.6748,
          "maximum": 1969.7062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 757.1083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 13X300MM 351.27",
      "code_information": [
        {
          "code": "3602773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3542,
          "minimum": 1210.8853,
          "maximum": 2570.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2364.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 360.05S",
      "code_information": [
        {
          "code": "3602774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4064,
          "minimum": 522.734,
          "maximum": 2949.2448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2713.3052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 38FR 68138",
      "code_information": [
        {
          "code": "3602784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 462,
          "minimum": 157.9416,
          "maximum": 42159.6093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 308.4515,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/15CM CA1815",
      "code_information": [
        {
          "code": "3602790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 11543.5238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 30FR 68130",
      "code_information": [
        {
          "code": "3602796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 418.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 384.5629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 32FR 68132",
      "code_information": [
        {
          "code": "3602797",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 602,
          "minimum": 205.8026,
          "maximum": 436.8714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 401.9217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 36FR 68136",
      "code_information": [
        {
          "code": "3602798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 418.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 384.5629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 34FR 68134",
      "code_information": [
        {
          "code": "3602799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR",
      "code_information": [
        {
          "code": "3602805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 436,
          "minimum": 149.0531,
          "maximum": 368.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 291.0928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94895",
      "code_information": [
        {
          "code": "3602818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 755.4537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 695.0174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94835",
      "code_information": [
        {
          "code": "3602819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 755.4537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 695.0174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3602851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 207.4253,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 852.5814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 16G/15CM CA1615",
      "code_information": [
        {
          "code": "3602858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 14G/11CM CA1411",
      "code_information": [
        {
          "code": "3602859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 553.8756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 X523H",
      "code_information": [
        {
          "code": "3602867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0  X513H",
      "code_information": [
        {
          "code": "3602868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.7321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7 W/QC STD TP 71933035",
      "code_information": [
        {
          "code": "3602893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 1656.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1523.5636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-W/ NEEDLES #0 SUTURE",
      "code_information": [
        {
          "code": "3602933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2016.2849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-EXTREMITIES UNIVERSAL",
      "code_information": [
        {
          "code": "3602935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1194",
      "code_information": [
        {
          "code": "3602936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 4768.0014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 641.6059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ201",
      "code_information": [
        {
          "code": "3602938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1157.2126,
          "maximum": 2456.4945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2259.9749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ101",
      "code_information": [
        {
          "code": "3602939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1157.2126,
          "maximum": 2509.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2259.9749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 180MM P45-112-0180",
      "code_information": [
        {
          "code": "3602943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 2249.4245,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4510.6029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 180MM P45-180-0180",
      "code_information": [
        {
          "code": "3602944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4045,
          "minimum": 1382.8434,
          "maximum": 2935.4565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2700.62,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-4H THRED P45-921-0004",
      "code_information": [
        {
          "code": "3602945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2618,
          "minimum": 870.8526,
          "maximum": 1899.8826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1747.892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CALIBRA 4X165MM 0225-000",
      "code_information": [
        {
          "code": "3602953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2376,
          "minimum": 812.2709,
          "maximum": 1922.9938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1586.3221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5MMPINX9.5MMROD 1151-200",
      "code_information": [
        {
          "code": "3602954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3458,
          "minimum": 1182.1687,
          "maximum": 2509.4706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2308.713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-9.5 X 9.5MM ROD 1151-200",
      "code_information": [
        {
          "code": "3602955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3458,
          "minimum": 1182.1687,
          "maximum": 2509.4706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2308.713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X150MM 1152-150",
      "code_information": [
        {
          "code": "3602956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X200MM 1152-200",
      "code_information": [
        {
          "code": "3602957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X250MM 1152-250",
      "code_information": [
        {
          "code": "3602958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X300 1152-300",
      "code_information": [
        {
          "code": "3602959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 3591.2938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN ASSEM 1158-000",
      "code_information": [
        {
          "code": "3602960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6458,
          "minimum": 1377.4597,
          "maximum": 4686.5706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4311.645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VENASEAL CLOSURE VS-404",
      "code_information": [
        {
          "code": "3602966",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1687.4449,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3295.4908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-5.5 P20-910-5500",
      "code_information": [
        {
          "code": "3602974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 1250.3811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1150.3506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK -.5 P20-915-5500",
      "code_information": [
        {
          "code": "3602976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 4037.8421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1150.3506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PROTECT 5.0 P45-198-5000",
      "code_information": [
        {
          "code": "3602978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5320",
      "code_information": [
        {
          "code": "3603015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1167,
          "minimum": 398.9563,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 779.1405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-150MM THRED P45-310-0150",
      "code_information": [
        {
          "code": "3603022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 1522.6018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 454.6656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-CUBE 4H P45-925-0004",
      "code_information": [
        {
          "code": "3603023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2738,
          "minimum": 870.8526,
          "maximum": 1986.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1828.0093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-3/16\\\" SQ P99-000-316P",
      "code_information": [
        {
          "code": "3603028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 199.0838,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 8MM P45-914-0003",
      "code_information": [
        {
          "code": "3603029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 9787.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.0166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ULTRALOOP-HS FIBER 72205445",
      "code_information": [
        {
          "code": "3603051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 575.5091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM PROBE 9700-020-100",
      "code_information": [
        {
          "code": "3603057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21773,
          "minimum": 1205.6248,
          "maximum": 15800.6661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14536.6128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/F P01-900-1702",
      "code_information": [
        {
          "code": "3603060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 358.6845,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1805.977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F40 64611",
      "code_information": [
        {
          "code": "3603068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63306",
      "code_information": [
        {
          "code": "3603069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.5229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63305",
      "code_information": [
        {
          "code": "3603070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 149.0348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.5229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE SMALL",
      "code_information": [
        {
          "code": "3603071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.9286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE LARGE",
      "code_information": [
        {
          "code": "3603072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.9286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE MEDIUM",
      "code_information": [
        {
          "code": "3603073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 45.6002,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 178.9286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYNG SZ4 321400000U",
      "code_information": [
        {
          "code": "3603074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 165.7178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL WIDE",
      "code_information": [
        {
          "code": "3603075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL FITPACK",
      "code_information": [
        {
          "code": "3603076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 129.5229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X400MM 1152-400",
      "code_information": [
        {
          "code": "3603081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 60.0588,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1541.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP427H",
      "code_information": [
        {
          "code": "3603082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 2619.7871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOULTION-WOUND VASHE 118ML",
      "code_information": [
        {
          "code": "3603095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 225,
          "minimum": 76.9196,
          "maximum": 176.8398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 150.2199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ULTRABRAID SZ2 7210915",
      "code_information": [
        {
          "code": "3603096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 35594.2927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 212.3108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-50 COBLATION 72290037",
      "code_information": [
        {
          "code": "3603101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1887,
          "minimum": 287.5037,
          "maximum": 1369.3959,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1259.8442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3603102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 517,
          "minimum": 176.7441,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 345.1719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-5.5 72202530",
      "code_information": [
        {
          "code": "3603103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 732.4055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-HRVST SYS SK27",
      "code_information": [
        {
          "code": "3603104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5613,
          "minimum": 1474.2211,
          "maximum": 4073.3541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3747.4858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INST-GUIDE RELEASE SN20",
      "code_information": [
        {
          "code": "3603105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 8186.3481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1769.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-HK BONE REMOVAL SN25",
      "code_information": [
        {
          "code": "3603107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1769.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRIPLE EDGE INST SN21",
      "code_information": [
        {
          "code": "3603108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 110.6639,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1769.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0 C013D",
      "code_information": [
        {
          "code": "3603114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 797.4474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 108.826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-FILSHIE AVM-851J",
      "code_information": [
        {
          "code": "3603115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1434,
          "minimum": 490.2342,
          "maximum": 8660.1453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 957.4015,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERC SUTURE AR-7267",
      "code_information": [
        {
          "code": "3603119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2217.9134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 14MM 2022-30-014S",
      "code_information": [
        {
          "code": "3603135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 1159.6686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1066.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 16MM 2022-30-016S",
      "code_information": [
        {
          "code": "3603136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 1159.6686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1066.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PIN PROT WHT 5027-1-040",
      "code_information": [
        {
          "code": "3603139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-DELIVERY STRBL-14F-075",
      "code_information": [
        {
          "code": "3603178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3603179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3201.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3603180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3201.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 8F",
      "code_information": [
        {
          "code": "3603181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3201.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 9F",
      "code_information": [
        {
          "code": "3603182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 51.7173,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3201.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 8MM 022108-10",
      "code_information": [
        {
          "code": "3603183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 712.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TPR 3MM 5407-FA3-030",
      "code_information": [
        {
          "code": "3603184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1282,
          "minimum": 438.2708,
          "maximum": 930.3474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 855.9196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 6MM 5820-010-160",
      "code_information": [
        {
          "code": "3603185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1494,
          "minimum": 510.7461,
          "maximum": 1084.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 997.4601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RASP-HELI 3.2MM 5120-080-030",
      "code_information": [
        {
          "code": "3603186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1446,
          "minimum": 494.3366,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 965.4132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 7205306",
      "code_information": [
        {
          "code": "3603188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 501.6022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 1683H",
      "code_information": [
        {
          "code": "3603192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 4507.1905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 49.4057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3603196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3050,
          "minimum": 178.5081,
          "maximum": 2213.385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2036.3142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT C0R47",
      "code_information": [
        {
          "code": "3603197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS CFF74",
      "code_information": [
        {
          "code": "3603198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 60.0588,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEEDLE WINGED INF WNIS01",
      "code_information": [
        {
          "code": "3603199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 914.2284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 72.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED CTF73",
      "code_information": [
        {
          "code": "3603214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANN-VENOUS HI FLO 24FR 69324",
      "code_information": [
        {
          "code": "3603215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 413,
          "minimum": 141.1902,
          "maximum": 4958.7437,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 275.737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A404",
      "code_information": [
        {
          "code": "3603218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 393,
          "minimum": 134.3529,
          "maximum": 364.8016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 262.3841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR 72201513",
      "code_information": [
        {
          "code": "3603219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 656,
          "minimum": 224.2633,
          "maximum": 476.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 437.9745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3603221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 615,
          "minimum": 210.2469,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 410.6011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SOMFIT 7037-1001-00",
      "code_information": [
        {
          "code": "3603227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 1705.5587,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 335.1573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MOD 12MM 2022-30-012S",
      "code_information": [
        {
          "code": "3603247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 1334.64,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1066.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3603277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 35676.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 159.5669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-ZINC OXIDE REMDEY 4OZ",
      "code_information": [
        {
          "code": "3603279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 1897.4132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.0733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT X 2.4/45° 378824",
      "code_information": [
        {
          "code": "3603290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 308,
          "minimum": 101.2102,
          "maximum": 223.5156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 205.6344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-STR SP 15° 378235",
      "code_information": [
        {
          "code": "3603291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 4507.1905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 121.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM BP 0808-115-800",
      "code_information": [
        {
          "code": "3603299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10281,
          "minimum": 1346.3181,
          "maximum": 7460.9217,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6864.048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-11G VP 0605-411-000",
      "code_information": [
        {
          "code": "3603300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2421,
          "minimum": 827.6548,
          "maximum": 1756.9197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1616.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-10G VP 0605-410-000",
      "code_information": [
        {
          "code": "3603301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2421,
          "minimum": 497.7095,
          "maximum": 1756.9197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1616.3661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BL 3X600 AR-9091BK-30S",
      "code_information": [
        {
          "code": "3603303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1769.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL 4.2MM AR-9091-42",
      "code_information": [
        {
          "code": "3603304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 26349.6863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1904.7883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CM VP 11G 0306-511-000",
      "code_information": [
        {
          "code": "3603319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 604,
          "minimum": 206.4864,
          "maximum": 2716.5485,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 403.257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5 REAMING 6143.2571",
      "code_information": [
        {
          "code": "3603340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 5862.9623,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2016.2849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM F/ANCHOR 72203785",
      "code_information": [
        {
          "code": "3603349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1506,
          "minimum": 514.8485,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1005.4719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X5MM 60-16005",
      "code_information": [
        {
          "code": "3603351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1284,
          "minimum": 438.9545,
          "maximum": 931.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 857.2549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X26MM 60-16526",
      "code_information": [
        {
          "code": "3603355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1442,
          "minimum": 492.9691,
          "maximum": 1046.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 962.7426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X35 92-16135",
      "code_information": [
        {
          "code": "3603356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1863,
          "minimum": 480.4704,
          "maximum": 1351.9791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1243.8208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X50/5M 60-15105",
      "code_information": [
        {
          "code": "3603363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1488,
          "minimum": 508.6949,
          "maximum": 1511.4798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 993.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X110/20M 60-15620",
      "code_information": [
        {
          "code": "3603364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 726.2666,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1814.6564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13X50/13G NN-2003",
      "code_information": [
        {
          "code": "3603396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 7026.8796,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14310.9491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL DIST 2.8MM 4040-000",
      "code_information": [
        {
          "code": "3603404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1975,
          "minimum": 675.1831,
          "maximum": 6311.1789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1318.5969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 1.5X230MM 0109-230",
      "code_information": [
        {
          "code": "3603406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1380.7963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 765.12,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE HAND 415S002350",
      "code_information": [
        {
          "code": "3603407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 848.8504,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1657.7601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CIRCUIT NEONATE DUAL LIMB",
      "code_information": [
        {
          "code": "3603429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 754,
          "minimum": 257.7661,
          "maximum": 547.1778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 503.4036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SUCTION TABLE 8Q70R",
      "code_information": [
        {
          "code": "3603430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 633,
          "minimum": 216.4005,
          "maximum": 909.7796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 422.6187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5X150 CN P41-910-5015",
      "code_information": [
        {
          "code": "3603431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1092.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AO CONN P65-001-0001-SK",
      "code_information": [
        {
          "code": "3603438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 6996.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-QUAD TIP 2762-01-0003",
      "code_information": [
        {
          "code": "3603444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 1078.5836,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2106.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2.5CM M00510880",
      "code_information": [
        {
          "code": "3603498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1143.0065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2CM M00510870",
      "code_information": [
        {
          "code": "3603499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 3296.0047,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1143.0065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GENERATOR-RF PROC RLVRFGPR",
      "code_information": [
        {
          "code": "3603504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 14704.3962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1232.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ADD ACCESS INST RLV0075",
      "code_information": [
        {
          "code": "3603508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 11091.9706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2636.5262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ACCESS INSTRUMENT RLV0045",
      "code_information": [
        {
          "code": "3603510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9838,
          "minimum": 3363.2665,
          "maximum": 7139.4366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6568.2817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DAVINCI INSUFF TUBE 470551",
      "code_information": [
        {
          "code": "3603512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1264,
          "minimum": 432.1172,
          "maximum": 3249.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 843.902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/10CM NN-8006",
      "code_information": [
        {
          "code": "3603527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 16702,
          "minimum": 1866.2716,
          "maximum": 12120.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 11150.9901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X60/13G NN-2004",
      "code_information": [
        {
          "code": "3603530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 632.2857,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14310.9491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 40X11 SM-4011M",
      "code_information": [
        {
          "code": "3603538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 3296.0047,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ALLOGRAFT-22.5MM ABS-4057D-225",
      "code_information": [
        {
          "code": "3603542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5686,
          "minimum": 1943.8436,
          "maximum": 4126.3302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3796.2238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL-1.5x48MM 03.130.212",
      "code_information": [
        {
          "code": "3603544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 124.0103,
          "maximum": 751.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP76",
      "code_information": [
        {
          "code": "3603545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 148.8846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE 9X102 HTOE 05-306",
      "code_information": [
        {
          "code": "3603547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 285.9258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 263.0517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.35X150 AR-8943-01S",
      "code_information": [
        {
          "code": "3603548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.9579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLECTOR-SPECIMEN NN-9002",
      "code_information": [
        {
          "code": "3603569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 700,
          "minimum": 239.3054,
          "maximum": 793.5547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 467.3508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/13CM NN-8007",
      "code_information": [
        {
          "code": "3603587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 18660,
          "minimum": 6379.1983,
          "maximum": 13541.562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 12458.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X95/13G NN-2006",
      "code_information": [
        {
          "code": "3603588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 7327.8733,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14310.9491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X75/13G NN-2005",
      "code_information": [
        {
          "code": "3603589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 62.8393,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 14310.9491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-MYRID NICO NN-9001",
      "code_information": [
        {
          "code": "3603590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 551.6512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 7FRX65C",
      "code_information": [
        {
          "code": "3603592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1624,
          "minimum": 555.1885,
          "maximum": 1178.5368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1084.2539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 5FRX50C",
      "code_information": [
        {
          "code": "3603593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1624,
          "minimum": 555.1885,
          "maximum": 1178.5368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1084.2539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 9FRX65C",
      "code_information": [
        {
          "code": "3603594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1882,
          "minimum": 643.3897,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1256.506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-20-22FR/45CM G52835",
      "code_information": [
        {
          "code": "3603768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1759,
          "minimum": 601.3403,
          "maximum": 1276.5063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1174.3858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16-18FR/45CM G52834",
      "code_information": [
        {
          "code": "3603769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1759,
          "minimum": 601.3403,
          "maximum": 2381.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1174.3858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-32-35MM 102024003",
      "code_information": [
        {
          "code": "3603771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 2465.7474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1769.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.4X27 ST 60-14126",
      "code_information": [
        {
          "code": "3603794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 3325.478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 742.4201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOWN-WARMING BEAR PAW 81001",
      "code_information": [
        {
          "code": "3603809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 6791.0932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.5024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPYSCOPE DS II M00546610",
      "code_information": [
        {
          "code": "3603810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12212,
          "minimum": 1866.2716,
          "maximum": 8862.2484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8153.2685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-EHL 1.9F 375CM M00546620",
      "code_information": [
        {
          "code": "3603814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2879,
          "minimum": 984.2289,
          "maximum": 2089.2903,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1922.1471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONEMILL MD 5420-MED-000",
      "code_information": [
        {
          "code": "3603815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3354,
          "minimum": 1146.6147,
          "maximum": 5094.4321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2239.278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CRV DIAMOND 15° 1600650",
      "code_information": [
        {
          "code": "3603818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CYLINDER 60° 1600578",
      "code_information": [
        {
          "code": "3603819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1120.3066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X200MM P99-192-1620",
      "code_information": [
        {
          "code": "3603836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 6.6732,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.6469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2.0 3846T",
      "code_information": [
        {
          "code": "3603837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 8.7084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8.0117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 7-0 Z135H",
      "code_information": [
        {
          "code": "3603876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 273,
          "minimum": 93.3291,
          "maximum": 9887.458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 182.2668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 45X6 SM-4506",
      "code_information": [
        {
          "code": "3603888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 8750.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-38MM ARS743201",
      "code_information": [
        {
          "code": "3603895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1048.8687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-14X127MM ARS743303",
      "code_information": [
        {
          "code": "3603897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 1140.0747,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1048.8687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE .9MM 57S90005",
      "code_information": [
        {
          "code": "3603901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 468.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 430.6304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM MXM-072-19",
      "code_information": [
        {
          "code": "3603904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1201.0916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-76/3 ARS743202",
      "code_information": [
        {
          "code": "3603910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1048.8687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 8.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603923",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 6.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 49.4929,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 169.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SM CHLD NR34015813",
      "code_information": [
        {
          "code": "3603926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.4203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015814",
      "code_information": [
        {
          "code": "3603927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 59.4203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PRO-FLOW NR37000145",
      "code_information": [
        {
          "code": "3603928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMETRY EM951160CP",
      "code_information": [
        {
          "code": "3603931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 41.7075,
          "maximum": 148.0428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.1994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ADULT NR34015818",
      "code_information": [
        {
          "code": "3603932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 54.4275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.0733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASALNR354S5011",
      "code_information": [
        {
          "code": "3603933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 45.6002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015816",
      "code_information": [
        {
          "code": "3603934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 72.8491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.7468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG WEBB NR104B1420",
      "code_information": [
        {
          "code": "3603935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 131,
          "minimum": 44.7843,
          "maximum": 294.1769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 87.4614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-EEG 8OZ NR10200005",
      "code_information": [
        {
          "code": "3603936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 529,
          "minimum": 87.8638,
          "maximum": 383.8953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 353.1837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUPREP-4OZ TUBE NR10210004",
      "code_information": [
        {
          "code": "3603937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 32.8099,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 105.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THERMOCAN NR34015808",
      "code_information": [
        {
          "code": "3603938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 17894.7419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 39.391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR/6.7MM 80220",
      "code_information": [
        {
          "code": "3603955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 258.3782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CLEARVUE LARYNG #3",
      "code_information": [
        {
          "code": "3603957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 135.5317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NOMOLINE LH NASAL/ORAL",
      "code_information": [
        {
          "code": "3603958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 150.9456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 138.87,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 22FR BE2050",
      "code_information": [
        {
          "code": "3603960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 864.3087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 795.164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LITHOTRIPER PROBE 3.9MM",
      "code_information": [
        {
          "code": "3603972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4400,
          "minimum": 1504.2054,
          "maximum": 3193.08,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2937.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T-15 TORQUE 702750",
      "code_information": [
        {
          "code": "3603979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3611,
          "minimum": 1234.474,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2410.8625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIMITER-TORQUE 2.5NM 702760",
      "code_information": [
        {
          "code": "3603985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4015,
          "minimum": 1372.5874,
          "maximum": 4387.0729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2680.5907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/15 STPL THN00482",
      "code_information": [
        {
          "code": "3603988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2099,
          "minimum": 717.5743,
          "maximum": 1523.2443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1401.3848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/20 STPL THN00483",
      "code_information": [
        {
          "code": "3603989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2099,
          "minimum": 717.5743,
          "maximum": 1523.2443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1401.3848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA 22.5FR 7275",
      "code_information": [
        {
          "code": "3604022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM*CLEARIFY 21-345",
      "code_information": [
        {
          "code": "3604025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 255.04,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 CHROMIC GUT 792G",
      "code_information": [
        {
          "code": "3604027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 85.4662,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 166.911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-NANO 29.5X7MM SM-3115",
      "code_information": [
        {
          "code": "3604043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-MET 20MM MPN20120",
      "code_information": [
        {
          "code": "3604048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2217.9134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHAL 20MM MPN20020",
      "code_information": [
        {
          "code": "3604049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 667.8761,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2217.9134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM SHT MSTD1030",
      "code_information": [
        {
          "code": "3604050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE DUAL 844023S",
      "code_information": [
        {
          "code": "3604137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 291,
          "minimum": 71.1808,
          "maximum": 211.1787,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 194.2844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 2X200 MSG20200",
      "code_information": [
        {
          "code": "3604156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 1511.4798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 478.0331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.6 F/5.5MM MSN10013",
      "code_information": [
        {
          "code": "3604157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 667.8761,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1814.6564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM LNG MSTD0030",
      "code_information": [
        {
          "code": "3604158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 2274.449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 801.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA-G GENERATION 2",
      "code_information": [
        {
          "code": "3604162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10740,
          "minimum": 3671.6286,
          "maximum": 7794.018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 7170.4966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-STAPLE SZ THN00292",
      "code_information": [
        {
          "code": "3604165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1344.635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 5.0MM 3100-01-0005",
      "code_information": [
        {
          "code": "3604167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 795.7791,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2241.2809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 2.4MM 2900-04-0229",
      "code_information": [
        {
          "code": "3604168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1431,
          "minimum": 489.2086,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 955.3986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-6.5MM 3100-01-0007",
      "code_information": [
        {
          "code": "3604169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 1147.6403,
          "maximum": 8783.5995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2241.2809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-7X90 3200-01-7090",
      "code_information": [
        {
          "code": "3604170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 15795,
          "minimum": 5399.7555,
          "maximum": 11462.4315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 10545.437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SONATA DE-001-10",
      "code_information": [
        {
          "code": "3604172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 877,
          "minimum": 278.05,
          "maximum": 636.4389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 585.5238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS BONE BX 0306-115-000",
      "code_information": [
        {
          "code": "3604196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 798,
          "minimum": 272.8082,
          "maximum": 4376.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 532.7799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-DSG XS 2.5MM P1-AU514",
      "code_information": [
        {
          "code": "3604197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 551.6512,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 5254.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DISTRACTOR 12MM 02.600.022",
      "code_information": [
        {
          "code": "3604198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 662.3028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-#0/8\\\"\\\" GREEN VLOCA008L",
      "code_information": [
        {
          "code": "3604209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1317,
          "minimum": 450.236,
          "maximum": 955.7469,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 879.2871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX977",
      "code_information": [
        {
          "code": "3604217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 507.7193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 213.6461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ACESSA 7300",
      "code_information": [
        {
          "code": "3604227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14892,
          "minimum": 265.8158,
          "maximum": 10807.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9942.5544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-HEAD SILVERMAN SZ F",
      "code_information": [
        {
          "code": "3604228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X12MM AR-300-B003",
      "code_information": [
        {
          "code": "3604244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 1790.3019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1647.0777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUT 2 P41-960-0020",
      "code_information": [
        {
          "code": "3604263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 1250.3811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1150.3506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5.5X150 CN P41-910-5515",
      "code_information": [
        {
          "code": "3604264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1187.2452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1092.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X150 CN P41-910-4015",
      "code_information": [
        {
          "code": "3604265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1187.2452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1092.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-GPS LONG 6143.2515",
      "code_information": [
        {
          "code": "3604278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6702,
          "minimum": 836.3744,
          "maximum": 4863.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 4474.5501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 8.0",
      "code_information": [
        {
          "code": "3604284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 7.5",
      "code_information": [
        {
          "code": "3604285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED",
      "code_information": [
        {
          "code": "3604286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER TRACH PORTEX 100",
      "code_information": [
        {
          "code": "3604287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 51.7173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 38.7234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEMALE TO FEMALE",
      "code_information": [
        {
          "code": "3604289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 1322.9619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-1.8MM PERK AR-3610PK-3",
      "code_information": [
        {
          "code": "3604294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1586,
          "minimum": 542.1977,
          "maximum": 1763.3931,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1058.8834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SR8 GEMINI AR-6572",
      "code_information": [
        {
          "code": "3604301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 3149.1943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 267.7252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLSRE SKN 22CM EF70401",
      "code_information": [
        {
          "code": "3604305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 711,
          "minimum": 243.0659,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 474.6949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH 14 1/4\\\" 020116801",
      "code_information": [
        {
          "code": "3604307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 871.2754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-TISSUE HIGH EX71010",
      "code_information": [
        {
          "code": "3604311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-WIRE FIX XL 76-10104",
      "code_information": [
        {
          "code": "3604319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1375,
          "minimum": 470.0642,
          "maximum": 997.8375,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 918.0105,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR PEDIATRIC S-1003",
      "code_information": [
        {
          "code": "3604329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 264,
          "minimum": 90.2523,
          "maximum": 5757.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 176.258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT SHORT 71-6130S",
      "code_information": [
        {
          "code": "3604330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10354,
          "minimum": 870.8526,
          "maximum": 7513.8978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 6912.786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 4H 76-10140",
      "code_information": [
        {
          "code": "3604333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1129.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 2H 76-10125",
      "code_information": [
        {
          "code": "3604334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1129.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 200MM 76-11200",
      "code_information": [
        {
          "code": "3604335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1151,
          "minimum": 207.4253,
          "maximum": 835.2807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 768.4582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 115MM 76-11115",
      "code_information": [
        {
          "code": "3604337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 934,
          "minimum": 319.3018,
          "maximum": 3255.4094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 623.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FH 4.2MM AR-9091F-42",
      "code_information": [
        {
          "code": "3604351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1904.7883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CON 4.3X13MM AR-300-B101",
      "code_information": [
        {
          "code": "3604352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2470,
          "minimum": 7.7854,
          "maximum": 1792.479,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1649.0807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE SKIN EF70466",
      "code_information": [
        {
          "code": "3604355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 933,
          "minimum": 101.7663,
          "maximum": 677.0781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 622.9119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEN-ADHESIVE EP70412",
      "code_information": [
        {
          "code": "3604356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.1789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACTIVALVE-PROVOX STRONG 7161",
      "code_information": [
        {
          "code": "3604357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 662.3151,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2636.5262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET ACCESS INST LV3 RLV0055",
      "code_information": [
        {
          "code": "3604369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12997,
          "minimum": 3490.6397,
          "maximum": 9431.9229,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8677.3691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.6X200 AR-5050K-1",
      "code_information": [
        {
          "code": "3604376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 319.1338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM RC P01-DWL-0915",
      "code_information": [
        {
          "code": "3604386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3766.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-FOGARTY DSOFT33",
      "code_information": [
        {
          "code": "3604398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 241.0195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-DRAIN/FLUSH LL AFA-LL",
      "code_information": [
        {
          "code": "3604403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 149.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #4",
      "code_information": [
        {
          "code": "3604406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 294.6342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 271.0635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-6 THD/10 HEX 76-10180",
      "code_information": [
        {
          "code": "3604415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 235,
          "minimum": 80.3382,
          "maximum": 175.1715,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 156.8963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-FLANGE 10HX 76-10182",
      "code_information": [
        {
          "code": "3604416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 3503.9861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 210.3079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD +3OS/25MM MWJ007",
      "code_information": [
        {
          "code": "3604423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5858,
          "minimum": 580.5684,
          "maximum": 4251.1506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 3911.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODEL-REV BONE MWJ015",
      "code_information": [
        {
          "code": "3604424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 14259.5162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.0 A-3938",
      "code_information": [
        {
          "code": "3604432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2061,
          "minimum": 506.051,
          "maximum": 1495.6677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1376.0143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 16FR 26-016",
      "code_information": [
        {
          "code": "3604433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 660.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 607.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 12FR 26-012",
      "code_information": [
        {
          "code": "3604434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 660.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 607.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 18FR 26-018",
      "code_information": [
        {
          "code": "3604435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 607.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-6X150 CN P41-910-6015",
      "code_information": [
        {
          "code": "3604457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1092.2656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CAL 5.5MM S0288-200",
      "code_information": [
        {
          "code": "3604470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2470,
          "minimum": 844.4062,
          "maximum": 3563.4888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1649.0807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.6MM TRC AR-18700-71",
      "code_information": [
        {
          "code": "3604479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 638.9589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 199.6256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO",
      "code_information": [
        {
          "code": "3604489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 686,
          "minimum": 71.1808,
          "maximum": 497.8302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 458.0038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1069210",
      "code_information": [
        {
          "code": "3604490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 4015.5981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-HO 7/1.6X80 P99-205-1608",
      "code_information": [
        {
          "code": "3604512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1065,
          "minimum": 364.0861,
          "maximum": 877.5258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 711.0409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GRAFT SIZING AR-1676ST",
      "code_information": [
        {
          "code": "3604518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 8964.332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1388.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMANN .157X9\\\"\\\" KI71615",
      "code_information": [
        {
          "code": "3604550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 131.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL SP-78105",
      "code_information": [
        {
          "code": "3604567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1274,
          "minimum": 435.5358,
          "maximum": 924.5418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 850.5785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 1MM 5820-013-010",
      "code_information": [
        {
          "code": "3604568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 427.6409,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 852.5814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 12X18/2 DS24",
      "code_information": [
        {
          "code": "3604569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 769,
          "minimum": 262.8941,
          "maximum": 558.0633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 513.4182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/0 DS26",
      "code_information": [
        {
          "code": "3604570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 832,
          "minimum": 284.4316,
          "maximum": 603.7824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 555.4798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 29/37 TF2937O",
      "code_information": [
        {
          "code": "3604581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 407.2628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-AMPLATZ 8F M0062601010",
      "code_information": [
        {
          "code": "3604584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 481,
          "minimum": 164.437,
          "maximum": 349.0617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 321.1368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEM 19F/6.3 96570-119",
      "code_information": [
        {
          "code": "3604596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2245,
          "minimum": 767.4866,
          "maximum": 1629.1965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1498.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 19F/6.3MM 96530-119",
      "code_information": [
        {
          "code": "3604597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 848.8504,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1657.7601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 21F/7MM 96530-121",
      "code_information": [
        {
          "code": "3604598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 134.0201,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1657.7601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WHITE 15X12MM DLP-W11",
      "code_information": [
        {
          "code": "3604599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-YELLOW 15X12MM DLP-S11",
      "code_information": [
        {
          "code": "3604600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 160.9022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-11MM 261222",
      "code_information": [
        {
          "code": "3604605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 1943.4246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1787.9506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 650-750CC SZHP68650",
      "code_information": [
        {
          "code": "3604611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 550-640CC SZHP68550",
      "code_information": [
        {
          "code": "3604612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 425-455CC SZHP68425",
      "code_information": [
        {
          "code": "3604613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 320-340CC SZHP68320",
      "code_information": [
        {
          "code": "3604614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 549,
          "minimum": 187.6838,
          "maximum": 398.4093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 366.5366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 200-260CC SZHP68200",
      "code_information": [
        {
          "code": "3604615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 750-800CC SZHP68750",
      "code_information": [
        {
          "code": "3604616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 577.6572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 531.4446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 2MM 5820-010-120",
      "code_information": [
        {
          "code": "3604621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 3MM 5820-010-130",
      "code_information": [
        {
          "code": "3604622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 4MM 5820-010-140",
      "code_information": [
        {
          "code": "3604623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 3MM 5820-012-030",
      "code_information": [
        {
          "code": "3604624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 436.5614,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 852.5814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 4MM 5820-012-040",
      "code_information": [
        {
          "code": "3604625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1494,
          "minimum": 510.7461,
          "maximum": 1084.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 997.4601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 3 5820-013-030",
      "code_information": [
        {
          "code": "3604626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 4 5820-013-040",
      "code_information": [
        {
          "code": "3604627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 911.3341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SAHARA S-1150-08LF",
      "code_information": [
        {
          "code": "3604628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1182,
          "minimum": 37.8148,
          "maximum": 857.7774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 789.1552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 20FR 123120",
      "code_information": [
        {
          "code": "3604629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12X150MM FE CFF71",
      "code_information": [
        {
          "code": "3604631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X150MM FE CFF01",
      "code_information": [
        {
          "code": "3604632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X100MM BLADE CFB03",
      "code_information": [
        {
          "code": "3604633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 47.2685,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 9MM 022109-10",
      "code_information": [
        {
          "code": "3604634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 61.6845,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 10MM 022110-10",
      "code_information": [
        {
          "code": "3604635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 12MM 022112-10",
      "code_information": [
        {
          "code": "3604636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 62.0909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 14MM 022114-10",
      "code_information": [
        {
          "code": "3604637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.7615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 16MM 022116-10",
      "code_information": [
        {
          "code": "3604638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGAMAX 5MM CLIP EL5ML",
      "code_information": [
        {
          "code": "3000771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1389,
          "minimum": 474.8503,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 927.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380EM",
      "code_information": [
        {
          "code": "3003259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 1089.8652,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2128.4491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-I-STAT CREATININE",
      "code_information": [
        {
          "code": "3004750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.7497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 22FR 30CC      266722",
      "code_information": [
        {
          "code": "3004837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 44.0645,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CORONARY PERF    30055",
      "code_information": [
        {
          "code": "3010039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 231.6725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE LITE 30-403LITE",
      "code_information": [
        {
          "code": "3010311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3419,
          "minimum": 1168.836,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2282.6748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN TWIST 2.7MM W/AO F",
      "code_information": [
        {
          "code": "3012109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2077,
          "minimum": 710.0533,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1386.6966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.0MM ASNIS",
      "code_information": [
        {
          "code": "3012113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1913,
          "minimum": 653.9875,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1277.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP NICU HNICU37",
      "code_information": [
        {
          "code": "3019903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z463G",
      "code_information": [
        {
          "code": "3032618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 63.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3058698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 919,
          "minimum": 314.1738,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 613.5648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPINPERC INS-5600",
      "code_information": [
        {
          "code": "3058755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2207,
          "minimum": 754.4957,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1473.4903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE 1.5X36",
      "code_information": [
        {
          "code": "3058775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 558.1504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 CX ALL",
      "code_information": [
        {
          "code": "3058846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2824.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PED 900PT531",
      "code_information": [
        {
          "code": "3059068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 722,
          "minimum": 246.8264,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 482.039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-ABSOLUTE PSI-TEC",
      "code_information": [
        {
          "code": "3059124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 229.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LIGASURE SM  LF1212A",
      "code_information": [
        {
          "code": "3059951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3010,
          "minimum": 1029.0132,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2009.6084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-LEVER EDGE    4100-01",
      "code_information": [
        {
          "code": "3059965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1454,
          "minimum": 497.0715,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 970.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST-OP XL MALE      1315",
      "code_information": [
        {
          "code": "3079661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 93.4702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL HEALTHVENT 24HR 97021",
      "code_information": [
        {
          "code": "3081122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 141.5405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-GLOW AND TELL     1100-20",
      "code_information": [
        {
          "code": "3083225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 191.1025,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 373.213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN CUFF 7.0MM",
      "code_information": [
        {
          "code": "3085522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 287.0869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM   70890830",
      "code_information": [
        {
          "code": "3526275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 57.4174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL EPISTAX 10CM",
      "code_information": [
        {
          "code": "3526349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 313.125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRING-MR EMPOWERCTA",
      "code_information": [
        {
          "code": "3526487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 136.867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR GYN DYNJ60136",
      "code_information": [
        {
          "code": "3527022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 190.7606,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 372.5454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MOMOPTY 20X15 21201",
      "code_information": [
        {
          "code": "3549005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 458,
          "minimum": 156.5741,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 305.781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-LAT VEIN WORLEY",
      "code_information": [
        {
          "code": "3549219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2264,
          "minimum": 773.982,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1511.546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-PCL 2.4MMX10",
      "code_information": [
        {
          "code": "3549231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 915.3399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Y-PORT-20 FR M00580641",
      "code_information": [
        {
          "code": "3549284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOAM-BUMP 10X6X6\\\" DYNJBUMP03",
      "code_information": [
        {
          "code": "3549293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-0xx-000",
      "code_information": [
        {
          "code": "3549839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CEMENT MIX 0206-015-000",
      "code_information": [
        {
          "code": "3549999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 192.8118,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 376.5512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-INTERLOCKING 3MMX4CM M001",
      "code_information": [
        {
          "code": "3550029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2529,
          "minimum": 864.5762,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1688.4717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-W/F L&L PED ALL 5002s",
      "code_information": [
        {
          "code": "3550092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-BRILL 3.5 682.108S",
      "code_information": [
        {
          "code": "3550131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 303.1104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP 180-210CC",
      "code_information": [
        {
          "code": "3550332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 279.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL",
      "code_information": [
        {
          "code": "3550461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 663.6381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STEM 2862-02-204",
      "code_information": [
        {
          "code": "3550481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1568.2958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT LARGE YG-282T",
      "code_information": [
        {
          "code": "3550639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 127.52,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 0200-20",
      "code_information": [
        {
          "code": "3550659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 473.141,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 924.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-BONE 3.8X13CM AR-8380BC",
      "code_information": [
        {
          "code": "3550684",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 526.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110MM 213524",
      "code_information": [
        {
          "code": "3550809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 630.9236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CLEARCUT 5X13 AR-8500COS",
      "code_information": [
        {
          "code": "3550848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 526.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND 2.5MM 1882569HS",
      "code_information": [
        {
          "code": "3559015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1938,
          "minimum": 662.5341,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1293.8941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LAMINARIA-#4 MED 60MM 021004",
      "code_information": [
        {
          "code": "3559244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 92.8025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT OPEN EB240",
      "code_information": [
        {
          "code": "3559437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1523.5636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X56MM 03.130.202",
      "code_information": [
        {
          "code": "3559456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV",
      "code_information": [
        {
          "code": "3559628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.1173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWRIST 2.5MM 60-25326",
      "code_information": [
        {
          "code": "3559663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 742.4201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARDS-NEONATAL NOISE NON-MAG",
      "code_information": [
        {
          "code": "3598028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 215,
          "minimum": 73.5009,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 143.5435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-MULTIPURPOSE TUBING",
      "code_information": [
        {
          "code": "3598219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.8582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUB LIPO 3-TT-FILTRON",
      "code_information": [
        {
          "code": "3598384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2403,
          "minimum": 821.5013,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1604.3485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW 25CM NSLX125C",
      "code_information": [
        {
          "code": "3598495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2676,
          "minimum": 914.8304,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1786.6153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN",
      "code_information": [
        {
          "code": "3598509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1055,
          "minimum": 360.6674,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 704.3644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3598587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 558.1504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND HANZ RT LG",
      "code_information": [
        {
          "code": "3599041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 494,
          "minimum": 168.8812,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 329.8161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ATERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 170.2492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-SELF LOCKING 4933-0-802",
      "code_information": [
        {
          "code": "3600214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 125.5171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-6MM/SD PARA 108843106",
      "code_information": [
        {
          "code": "3600452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2636.5262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-EAR DISP 4015",
      "code_information": [
        {
          "code": "3600557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 201.6285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CADD PCA 108” 21-7391-24",
      "code_information": [
        {
          "code": "3600723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.1642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT FEEDINGTUBE G3561",
      "code_information": [
        {
          "code": "3600751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 518.0917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-LF",
      "code_information": [
        {
          "code": "3600788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1948.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 10' 251010J",
      "code_information": [
        {
          "code": "3600900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 214.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-SUCT&ANTICOAG BT275",
      "code_information": [
        {
          "code": "3601009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 130.8582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS BIPOLAR 2MM",
      "code_information": [
        {
          "code": "3601053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1667,
          "minimum": 569.8887,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1112.9625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-100-4630",
      "code_information": [
        {
          "code": "3601111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1868.7356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-HEAD 17.5 03.404.031S",
      "code_information": [
        {
          "code": "3601120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3893,
          "minimum": 1330.8799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2599.1381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLUE STAPLE GCR40B",
      "code_information": [
        {
          "code": "3601345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1903,
          "minimum": 650.5688,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1270.5265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47520",
      "code_information": [
        {
          "code": "3601391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 836.5579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 11X100MM 4922-8-100",
      "code_information": [
        {
          "code": "3601641",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1743,
          "minimum": 595.8705,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1163.7035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.0MM",
      "code_information": [
        {
          "code": "3601769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 58.7527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE",
      "code_information": [
        {
          "code": "3602129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 864.599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 25MM X 15G",
      "code_information": [
        {
          "code": "3602700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1426,
          "minimum": 487.4993,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 952.0603,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCRW-POST+NUT SET B0223000",
      "code_information": [
        {
          "code": "3603037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1680.4599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOWS-SOLO FITPACK SLP1SMSLA",
      "code_information": [
        {
          "code": "3603077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 96.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREADED CTF03",
      "code_information": [
        {
          "code": "3603177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGATION P65-001-0006-SK",
      "code_information": [
        {
          "code": "3603437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1316,
          "minimum": 449.8942,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 878.6195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE SINGLE 800099S",
      "code_information": [
        {
          "code": "3604138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 85.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATE STD 20MM M0056183",
      "code_information": [
        {
          "code": "3604224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 297,
          "minimum": 101.5339,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 198.2903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 3.1X20MM AR-300-B202",
      "code_information": [
        {
          "code": "3604247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1647.0777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM C P01-901-0901-S",
      "code_information": [
        {
          "code": "3604385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1805.977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET SCREW T7 5560010000",
      "code_information": [
        {
          "code": "3604395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 301.8667,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 589.5297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #3",
      "code_information": [
        {
          "code": "3604407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 271.0635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-COAXIAL BIPSY 946x-VC-006",
      "code_information": [
        {
          "code": "1416380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 154.5958,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OPTIFIX-ABSORBABLE 0113126",
      "code_information": [
        {
          "code": "3000012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1095.517,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 7.3     310.495",
      "code_information": [
        {
          "code": "3002265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT LARYNGEAL 4MM",
      "code_information": [
        {
          "code": "3003289",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 431.5336,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OXFORD SAW 506298",
      "code_information": [
        {
          "code": "3003294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 432.0897,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-TUR PK           786500",
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        {
          "code": "3003816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 710.1397,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 96370-023",
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        {
          "code": "3004233",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 988.1897,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-020",
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        {
          "code": "3008516",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 11X280       357.404",
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        {
          "code": "3012311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2482.4304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX     2274-25-500",
      "code_information": [
        {
          "code": "3012384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 612.8222,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 7.0X3.2",
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        {
          "code": "3012900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-HALO CUTTING HACF-0533",
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        {
          "code": "3013285",
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        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 870.8526,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EVICEL FIBRIN SEALANT 3905",
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        {
          "code": "3021100",
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        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-SEALER 5MM     LF1637",
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        {
          "code": "3021738",
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
          "maximum": 13339.7268,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-TUR       784415 & 784515",
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        {
          "code": "3021867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 331.9917,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
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        {
          "code": "3021877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 824.6963,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NAVIGATED PAK9733498NAV",
      "code_information": [
        {
          "code": "3027426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 398.1676,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-OPEN HEART     DYNJ32033A",
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        {
          "code": "3029235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ULTRASOUND ALL SZ 840-7s",
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        {
          "code": "3034490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS EPIDUR VEIN",
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        {
          "code": "3044898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DEEP SCROTAL RETRACTION",
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        {
          "code": "3083072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 564.9976,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS1",
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        {
          "code": "3083596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 265.8158,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VERSAJET II 66800041",
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        {
          "code": "3091505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPEICE VERSAJET II 66800042",
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        {
          "code": "3091506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 45\\\" HARH45",
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        {
          "code": "3091507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-HEMOPERFUSION SKN602",
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        {
          "code": "3506295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 78.4101,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 018 XFR004118",
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          "code": "3526143",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 018 XFR004218",
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          "code": "3526144",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-ANCHORAGE CP XFR006100",
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          "code": "3526145",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 1119.9854,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-MARYLAND OPEN LF1937",
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          "code": "3526316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-ABIOMED .018\\\" 0052-3005",
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          "code": "3526913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ITEM-STRAIGHT 5450800307",
      "code_information": [
        {
          "code": "3526998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-UNIV SONIC 5450815114",
      "code_information": [
        {
          "code": "3527001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-VENTRIC PACING    D98100",
      "code_information": [
        {
          "code": "3533572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 107.8834,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.915S",
      "code_information": [
        {
          "code": "3547954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-7.0 CANNULATED 400146",
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        {
          "code": "3549092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSSEPTAL RF",
      "code_information": [
        {
          "code": "3549157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER A-2816",
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        {
          "code": "3549230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 762.4131,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 10MM 03.037.021",
      "code_information": [
        {
          "code": "3549749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 550 AC-10030120",
      "code_information": [
        {
          "code": "3549756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 563.3293,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRING 675.705S",
      "code_information": [
        {
          "code": "3550106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-8\\\" INSULATED 675.706S",
      "code_information": [
        {
          "code": "3550107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIPOLAR 675.170S",
      "code_information": [
        {
          "code": "3550116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 698.605S",
      "code_information": [
        {
          "code": "3550117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 17566.6429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER/SHAVER-ALL",
      "code_information": [
        {
          "code": "3550238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HAMMER-SLAP 694.008",
      "code_information": [
        {
          "code": "3550243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 7877.7126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-DIRECT MEASURE 702495",
      "code_information": [
        {
          "code": "3550617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 207.4253,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-HELIX 6.5 ADVANCE 222313",
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        {
          "code": "3550751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.7X160 A-8004.01",
      "code_information": [
        {
          "code": "3550825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 207.4253,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DRIVER 4 CANN A-8004.11",
      "code_information": [
        {
          "code": "3550827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1146.6782,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-LIGASURE 37CM LF1944",
      "code_information": [
        {
          "code": "3559070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 16MM XFR004216",
      "code_information": [
        {
          "code": "3559091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 6524.7213,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-WIRELESS CELL EX1151",
      "code_information": [
        {
          "code": "3559233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-15MM/3.5OS 9159.3035",
      "code_information": [
        {
          "code": "3559597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 2.0",
      "code_information": [
        {
          "code": "3559670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 134.5762,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3566817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 689.564,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40B GCS40B",
      "code_information": [
        {
          "code": "3598106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM 03.333.103",
      "code_information": [
        {
          "code": "3598147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 875.3014,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-STRT TIP BAYON 1590-01",
      "code_information": [
        {
          "code": "3598218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 108.9956,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH",
      "code_information": [
        {
          "code": "3598452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SUREFORM 60 480460",
      "code_information": [
        {
          "code": "3598611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 27CM APYX-27-TP",
      "code_information": [
        {
          "code": "3598956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 491.0363,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-1X10.5MM BI 632.678S",
      "code_information": [
        {
          "code": "3599051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERCLAGE AR-7268",
      "code_information": [
        {
          "code": "3599170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-CERCLAGE AR-7268T",
      "code_information": [
        {
          "code": "3599171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1128.883,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM 03.333.102",
      "code_information": [
        {
          "code": "3599533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 716.2568,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-NANO 125MM AR-3210-0043",
      "code_information": [
        {
          "code": "3600299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 667.8761,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-MINI COREDX M00515220",
      "code_information": [
        {
          "code": "3600762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3531.235,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR CVD GCS40G",
      "code_information": [
        {
          "code": "3600838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2679.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-LARGE DV2012-LF",
      "code_information": [
        {
          "code": "3600953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-8-13MM P99-110-0813",
      "code_information": [
        {
          "code": "3601104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-UNIVERSAL PAD ARTICGEL",
      "code_information": [
        {
          "code": "3601634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 4183.5403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIBER OPTIC PTEYE-1",
      "code_information": [
        {
          "code": "3602127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 600.588,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2848.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE 45\\\" HAR745",
      "code_information": [
        {
          "code": "3602909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE HAR736",
      "code_information": [
        {
          "code": "3602910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 149.5909,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA 13CM PRE1101US",
      "code_information": [
        {
          "code": "3603187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 253.0255,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 11G NN-1000",
      "code_information": [
        {
          "code": "3603528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 13G NN-1001",
      "code_information": [
        {
          "code": "3603586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 10376.826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY MAX M00546470",
      "code_information": [
        {
          "code": "3603811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL M00546550",
      "code_information": [
        {
          "code": "3603812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-RETRIEVAL M00546560",
      "code_information": [
        {
          "code": "3603813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-8MM/CV SF30 488530",
      "code_information": [
        {
          "code": "3603862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY 115CM G48240",
      "code_information": [
        {
          "code": "3603969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3975.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 25 LS96555-025",
      "code_information": [
        {
          "code": "3604574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SUPERLOOP TUR 784415",
      "code_information": [
        {
          "code": "3604601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 2240.6133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1411090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-20      G00810",
      "code_information": [
        {
          "code": "1414825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.1554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOFILTER-ASP FLTR",
      "code_information": [
        {
          "code": "3002210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 508,
          "minimum": 173.6673,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 339.1632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR",
      "code_information": [
        {
          "code": "3002324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 76.1114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM        388.394",
      "code_information": [
        {
          "code": "3002383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         60-20385",
      "code_information": [
        {
          "code": "3002391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1102,
          "minimum": 376.7351,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 735.7437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD DISP   8000-140",
      "code_information": [
        {
          "code": "3003251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 152.8905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-COLON CYTO        000110",
      "code_information": [
        {
          "code": "3003503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 107.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND S03.000.009S",
      "code_information": [
        {
          "code": "3003841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 360.5278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO SMALL  1320-3042S",
      "code_information": [
        {
          "code": "3012204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1181,
          "minimum": 403.7424,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 788.4876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM       60-19326",
      "code_information": [
        {
          "code": "3012208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 742.4201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0           310.21",
      "code_information": [
        {
          "code": "3012318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 648.95,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          310.288",
      "code_information": [
        {
          "code": "3012331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 691.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2           405883",
      "code_information": [
        {
          "code": "3012341",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1098,
          "minimum": 375.3676,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 733.0731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDISPEC        SE-1",
      "code_information": [
        {
          "code": "3012590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 549,
          "minimum": 187.6838,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 366.5366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RJ4 LC BIOPSY 160CM",
      "code_information": [
        {
          "code": "3013323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 90.7996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0MM 702460",
      "code_information": [
        {
          "code": "3016131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 242.3548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDETHREAD 150MM  292.72",
      "code_information": [
        {
          "code": "3016158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 461,
          "minimum": 157.5997,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 307.7839,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CRESCENT         74-1010",
      "code_information": [
        {
          "code": "3021150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 121,
          "minimum": 41.3656,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE LF 022701",
      "code_information": [
        {
          "code": "3029356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 713,
          "minimum": 243.7496,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 476.0302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PIGTAIL 28-0174",
      "code_information": [
        {
          "code": "3034526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1065,
          "minimum": 364.0861,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 711.0409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LAPAROSCOPIC 5MM  160655",
      "code_information": [
        {
          "code": "3034572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1151,
          "minimum": 393.4865,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 768.4582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM BLUE         XR60B",
      "code_information": [
        {
          "code": "3039920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 514,
          "minimum": 175.7185,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 343.169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD UNIV     050602",
      "code_information": [
        {
          "code": "3040461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 306,
          "minimum": 104.6106,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 204.2991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCISSORS-ENDODUT METZ     3142",
      "code_information": [
        {
          "code": "3044930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 460,
          "minimum": 157.2578,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 307.1162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY ALL 351-3000'sS",
      "code_information": [
        {
          "code": "3049750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 ORBIT 7205323",
      "code_information": [
        {
          "code": "3058626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 637,
          "minimum": 217.7679,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 425.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I KNIFE SURG 8065921552",
      "code_information": [
        {
          "code": "3058653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.7615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN LITE FUD023",
      "code_information": [
        {
          "code": "3058869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 51.4086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-HEEL PRESSURE MDT825",
      "code_information": [
        {
          "code": "3059240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 259.0459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION LARGE",
      "code_information": [
        {
          "code": "3059275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 272,
          "minimum": 92.9872,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 181.5992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SWANSON SUTURE  11-0675",
      "code_information": [
        {
          "code": "3060151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 662.3028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-RETRACTO 12\\\" 1041",
      "code_information": [
        {
          "code": "3060247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 78.1143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH      SZ5  A0A04",
      "code_information": [
        {
          "code": "3060306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 174.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-4.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3079259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 598.209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-VACURRETTE 5MM       21664",
      "code_information": [
        {
          "code": "3083764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 60.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-TUNNELING            1112",
      "code_information": [
        {
          "code": "3084399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 525,
          "minimum": 179.4791,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 350.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INFLATION   03.804.413S",
      "code_information": [
        {
          "code": "3084946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12X100MM     H12LP",
      "code_information": [
        {
          "code": "3085208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 702,
          "minimum": 239.9891,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 468.6861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SPIKE INFILTRATION",
      "code_information": [
        {
          "code": "3085534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 120.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX 116230",
      "code_information": [
        {
          "code": "3085546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 321.353,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 627.5854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM PROX",
      "code_information": [
        {
          "code": "3085796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 231.1006,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 451.3273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM VAS          XR30V",
      "code_information": [
        {
          "code": "3086955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 443,
          "minimum": 151.4461,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 295.7663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.8MM        292.68",
      "code_information": [
        {
          "code": "3091218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 623,
          "minimum": 212.9818,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 415.9422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT COLUMN 470341",
      "code_information": [
        {
          "code": "3115590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.2756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SYRINGE SSS-STP-SP",
      "code_information": [
        {
          "code": "3500008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 112.1642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-LARYNGOSCOPE DISP",
      "code_information": [
        {
          "code": "3518940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.0997,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POLYLOOP-LIGATING DEVICE HX-40",
      "code_information": [
        {
          "code": "3526123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 966,
          "minimum": 330.2415,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 644.9441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BASIC BREAST DYNJ60139",
      "code_information": [
        {
          "code": "3526420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1180,
          "minimum": 403.4005,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 787.8199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR HEAD/NECK",
      "code_information": [
        {
          "code": "3526670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 377,
          "minimum": 128.8831,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.7018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SUCTION 12.7 HI CAPACITY",
      "code_information": [
        {
          "code": "3527060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 45.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-BIOPSY MARQUEE",
      "code_information": [
        {
          "code": "3527097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 266.3127,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 520.0947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-ACOUSTIC RESPIRATION",
      "code_information": [
        {
          "code": "3541329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 337,
          "minimum": 115.2085,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 224.996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION OSTOMY BX 1500H",
      "code_information": [
        {
          "code": "3542454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ1",
      "code_information": [
        {
          "code": "3548009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 121,
          "minimum": 41.3656,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 80.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KCLAB2C",
      "code_information": [
        {
          "code": "3549038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.1789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULAIDE-CPAP SIZE 2, CA102-",
      "code_information": [
        {
          "code": "3549182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 166,
          "minimum": 56.7496,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 110.8289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HUMIDIFIER ATSVII BE-1010",
      "code_information": [
        {
          "code": "3549307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5M SHORT 6149.1037",
      "code_information": [
        {
          "code": "3549352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD BK-IS 109185",
      "code_information": [
        {
          "code": "3549411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 374.5483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE HINGED DONJOY",
      "code_information": [
        {
          "code": "3549781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 872,
          "minimum": 298.1062,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 582.1856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL SINGLE PK 1",
      "code_information": [
        {
          "code": "3549805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 662.3028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.6X30 SPEED 703894",
      "code_information": [
        {
          "code": "3550046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 937,
          "minimum": 320.3274,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 625.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST ALL SIZE 9105-00s",
      "code_information": [
        {
          "code": "3550085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 66.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X25MM 7005-3325",
      "code_information": [
        {
          "code": "3550159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 398.5835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STATLOCK-URO FOLEY FOL0105",
      "code_information": [
        {
          "code": "3550423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 40.7263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER",
      "code_information": [
        {
          "code": "3550432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 430.6304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153207",
      "code_information": [
        {
          "code": "3550599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 75.4438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXYTYKE INFNT W/7’ TUBING",
      "code_information": [
        {
          "code": "3550754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 48.738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0X150MM 705234",
      "code_information": [
        {
          "code": "3550888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 903,
          "minimum": 308.704,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 602.8825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4.5MM 080-453",
      "code_information": [
        {
          "code": "3559003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 179.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPREADER-SILIPOS GEL TOE MED",
      "code_information": [
        {
          "code": "3559185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 56.0821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 116239",
      "code_information": [
        {
          "code": "3559543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1039,
          "minimum": 355.1976,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 693.6821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-DRESSING CHANGE 4D",
      "code_information": [
        {
          "code": "3571200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 122.8465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE RCM-14815",
      "code_information": [
        {
          "code": "3598048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 839,
          "minimum": 286.8246,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 560.1533,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-REINFUSION SB1E",
      "code_information": [
        {
          "code": "3598227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 207.6373,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-Z-FLO FLUID",
      "code_information": [
        {
          "code": "3598273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 441,
          "minimum": 150.7624,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 294.431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 22GX.75\\\"",
      "code_information": [
        {
          "code": "3598320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 88.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHEST-DRAIN 4050-100N",
      "code_information": [
        {
          "code": "3598393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 318.4662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION SZ:8",
      "code_information": [
        {
          "code": "3598398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 229.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISTAL DUODENOVIDEOSCOPE",
      "code_information": [
        {
          "code": "3598674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 70.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Suture-7-0 Prolene Blue 8704H",
      "code_information": [
        {
          "code": "3598759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 180.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR PAPERELLA 510-043C",
      "code_information": [
        {
          "code": "3598871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 146.8817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X3.5MM AR-8741-14",
      "code_information": [
        {
          "code": "3600715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 406.5952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-12\\\" THD AR-8967KT-12",
      "code_information": [
        {
          "code": "3601044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 251.0341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CHEST VENT HYFIN TWINPACK",
      "code_information": [
        {
          "code": "3601126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 115.5024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 150MM 4933-1-150",
      "code_information": [
        {
          "code": "3601246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 527,
          "minimum": 180.1628,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 351.8484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC LARGE 313-9015W",
      "code_information": [
        {
          "code": "3601352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 188.9433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-3X7 AR-9300DS",
      "code_information": [
        {
          "code": "3601434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 827,
          "minimum": 282.7222,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 552.1416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON PEG ENFIT",
      "code_information": [
        {
          "code": "3601438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 64.7615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN 2.55MM MD 45303155",
      "code_information": [
        {
          "code": "3601456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 697.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TROCH 1.35MM AR-8737-02",
      "code_information": [
        {
          "code": "3601814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 209.6402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .045X5\\\" 5050-248",
      "code_information": [
        {
          "code": "3601940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 68.7673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXT-PERCUTANEOUS 9009",
      "code_information": [
        {
          "code": "3601976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 669.6469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED A/B",
      "code_information": [
        {
          "code": "3602055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 199.6256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-ORGO IRRIGATION 1502152",
      "code_information": [
        {
          "code": "3602107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 174.2551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HAWKINS 18GX15CM G05045",
      "code_information": [
        {
          "code": "3602657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 342.5014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X250 AO 1806-8018S",
      "code_information": [
        {
          "code": "3602902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1150,
          "minimum": 393.1446,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 767.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.35MM AR-5050-01",
      "code_information": [
        {
          "code": "3603040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 327.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOVIE-E-Z CLEAN 0014A",
      "code_information": [
        {
          "code": "3603224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 50.0733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 VICRYL PLUS VCP762D",
      "code_information": [
        {
          "code": "3603378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 142.8758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.9X27MM 60-19126",
      "code_information": [
        {
          "code": "3603820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 742.4201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y415H",
      "code_information": [
        {
          "code": "3603838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 8.0117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE 1.4MM 57S90004",
      "code_information": [
        {
          "code": "3603902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 430.6304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SPO2 ADULT NR37004030",
      "code_information": [
        {
          "code": "3603929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 54.0792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 18FR BE6050",
      "code_information": [
        {
          "code": "3603961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 795.164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CIRCUMCISION 1.45CM",
      "code_information": [
        {
          "code": "3604060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 605,
          "minimum": 206.8282,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 403.9246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VICRYL VCP104G",
      "code_information": [
        {
          "code": "3604215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 106.823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MINITAPE-LOOPED 72205435",
      "code_information": [
        {
          "code": "3604218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 913,
          "minimum": 312.1226,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 609.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 6X7 AR-6535TD",
      "code_information": [
        {
          "code": "3604297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 267.7252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7/F 2.4 AR-8916-18",
      "code_information": [
        {
          "code": "3604317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 358.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-NYLON 11MM/265ML CD005",
      "code_information": [
        {
          "code": "3604438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 438.6421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/2 DS28",
      "code_information": [
        {
          "code": "3604571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 815,
          "minimum": 278.6199,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 544.1299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-33MM LF EVERGRIP33",
      "code_information": [
        {
          "code": "3604594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 359,
          "minimum": 122.7295,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 239.6842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE    16G X 12.5",
      "code_information": [
        {
          "code": "1410723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 103.9907,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM         310.44",
      "code_information": [
        {
          "code": "3002798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 25.5806,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 125ML 04251",
      "code_information": [
        {
          "code": "3003421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 285.2793,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPORT II PAL-406LS",
      "code_information": [
        {
          "code": "3004250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 3.2X300MM",
      "code_information": [
        {
          "code": "3014238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 124.5664,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE  2839-xx-xxx",
      "code_information": [
        {
          "code": "3027302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 268.0402,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-TRIMANO BEACH CHAIR",
      "code_information": [
        {
          "code": "3034325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 11 G06732",
      "code_information": [
        {
          "code": "3059264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-4.5MM INCISOR PLUS",
      "code_information": [
        {
          "code": "3060481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30BL      TX30B",
      "code_information": [
        {
          "code": "3081557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 50.6051,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER   60-6085-20x",
      "code_information": [
        {
          "code": "3145100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3521005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 143.4738,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSDUCER TRUWAVE PX272",
      "code_information": [
        {
          "code": "3526526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 99.5419,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLOWSAFE II",
      "code_information": [
        {
          "code": "3549715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 56.7222,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-TRANSFUSION EXCHANGE",
      "code_information": [
        {
          "code": "3571501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 210.2058,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR CARE XL MULTI-USE",
      "code_information": [
        {
          "code": "3598079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/SHOULDER WRAP",
      "code_information": [
        {
          "code": "3598181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 10ML GIS-59",
      "code_information": [
        {
          "code": "3599411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 265.8158,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPAP BUBBLE MR290 CHAMBER",
      "code_information": [
        {
          "code": "3599616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 162.9373,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G ACCESS 03.804.517S",
      "code_information": [
        {
          "code": "3600911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 153.4836,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300S NTHRD 702463S",
      "code_information": [
        {
          "code": "3602409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 58.3905,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL",
      "code_information": [
        {
          "code": "3602464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 231.8937,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANTENNA-PROGRAMMER       37092",
      "code_information": [
        {
          "code": "3000651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        310.111",
      "code_information": [
        {
          "code": "3002241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2       AR-8944-22",
      "code_information": [
        {
          "code": "3002251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0          316.396",
      "code_information": [
        {
          "code": "3002271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1875.7253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM         310.31",
      "code_information": [
        {
          "code": "3002300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 913.1162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM         310.11",
      "code_information": [
        {
          "code": "3002784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2767.1536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM         310.26",
      "code_information": [
        {
          "code": "3002788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DISSECT ELECTRODE 139330",
      "code_information": [
        {
          "code": "3002955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW             511.9xxS",
      "code_information": [
        {
          "code": "3003266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS  03.000.3xxS",
      "code_information": [
        {
          "code": "3003268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 532.066S",
      "code_information": [
        {
          "code": "3003293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 225 ML04253",
      "code_information": [
        {
          "code": "3003420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 4MM PAL-404LLB",
      "code_information": [
        {
          "code": "3004044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-304LLB",
      "code_information": [
        {
          "code": "3004046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO PAL-304LM",
      "code_information": [
        {
          "code": "3004053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 5832.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHOLANGIOGRAM       C100",
      "code_information": [
        {
          "code": "3005220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR TITANIUM  FV012T",
      "code_information": [
        {
          "code": "3009771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3          316.402",
      "code_information": [
        {
          "code": "3012305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM AR-4160-35",
      "code_information": [
        {
          "code": "3012347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.141",
      "code_information": [
        {
          "code": "3012354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 310.25",
      "code_information": [
        {
          "code": "3012405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 926.4626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-558",
      "code_information": [
        {
          "code": "3012475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1960.8086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUGE 03.804.5x",
      "code_information": [
        {
          "code": "3020805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PREP     546102000",
      "code_information": [
        {
          "code": "3020926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 654.5297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 24FR      880-213",
      "code_information": [
        {
          "code": "3021819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE WATER",
      "code_information": [
        {
          "code": "3023171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTROSURG 134006",
      "code_information": [
        {
          "code": "3029511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL  1.5MM W/8.0MM STOP",
      "code_information": [
        {
          "code": "3058520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM CALIBRATED",
      "code_information": [
        {
          "code": "3058937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 12013.4283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 19 G05880",
      "code_information": [
        {
          "code": "3058996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 4706.8304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8943-",
      "code_information": [
        {
          "code": "3059000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 949.2627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-AIRWAY EXCH 8F G07833",
      "code_information": [
        {
          "code": "3059157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 5MM          CB5LT",
      "code_information": [
        {
          "code": "3079768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DOYLE II AIRWY 15-24055",
      "code_information": [
        {
          "code": "3080045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-                TLC-55",
      "code_information": [
        {
          "code": "3081528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30GRN     TX30G",
      "code_information": [
        {
          "code": "3081555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-8916-14",
      "code_information": [
        {
          "code": "3087940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CALIBRATED DRILL 2.5",
      "code_information": [
        {
          "code": "3087942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER     G3640x",
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        {
          "code": "3509540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BACK TABLE     DYNJ31777A",
      "code_information": [
        {
          "code": "3526152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VASCULAR LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3526426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE UNTHREAD 2X200MM",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 16/18 FR 96551",
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        {
          "code": "3527178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 664.5395,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET",
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        {
          "code": "3527263",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SOMA ADULT SAFB-SM/USA",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8426.0272,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DELIVERY NAVIFLEX 7FR.",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EPG CONNECTOR 53912D",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-NAIL 1806-1406S",
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        {
          "code": "3549850",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VORTRAN RESUSCITATION",
      "code_information": [
        {
          "code": "3550702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2020-00-335",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 11041.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-DRILLING COMP EL-DTS",
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        {
          "code": "3550764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1293.4886,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SPEED FEMORAL AE-1605",
      "code_information": [
        {
          "code": "3550845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SELECTOR-VEIN 57538CSV-WOR",
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        {
          "code": "3559121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 2416.2545,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-INSTRUMENT 0306-531-000",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 305.969,
          "maximum": 37149.7044,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-EXCELSIUS ARM 6143.2001S",
      "code_information": [
        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-MONITOR 6143.2003S",
      "code_information": [
        {
          "code": "3559498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/KNEE WRAP",
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        {
          "code": "3598180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 94725",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE MIXTURE",
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        {
          "code": "3598303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 1194.5028,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTYCORE 16GX7.5CM",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELBOW TRIMANO AR-1646",
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        {
          "code": "3598377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN 1.7/2.0 DRILL 45-20011",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.1X150MM 03.333.001",
      "code_information": [
        {
          "code": "3599532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.5X150MM QC 03.133.109",
      "code_information": [
        {
          "code": "3599727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-90° SAG 2296-003-109S2",
      "code_information": [
        {
          "code": "3599964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 305.969,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3600835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 16H 76-9103",
      "code_information": [
        {
          "code": "3600836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 24H 76-9104",
      "code_information": [
        {
          "code": "3600837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB NTHRD AR-18800-11",
      "code_information": [
        {
          "code": "3600896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8315.3633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE STER 03.804.519S",
      "code_information": [
        {
          "code": "3600903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X330 S0100-000",
      "code_information": [
        {
          "code": "3601632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 749.0667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FISTULA FUNNEL",
      "code_information": [
        {
          "code": "3601648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2901.7298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE BVT 03.804.520S",
      "code_information": [
        {
          "code": "3601878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8783.5995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE RUNTHRU 180 25-5211",
      "code_information": [
        {
          "code": "3601952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 15224.3497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE ARTERIAL ART356",
      "code_information": [
        {
          "code": "3602029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION PD-IT",
      "code_information": [
        {
          "code": "3602078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OIL-BIENAIR LUBRIFLUID 1600064",
      "code_information": [
        {
          "code": "3602105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE 16G X 16.5",
      "code_information": [
        {
          "code": "3602125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2613.67,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 914.2284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREDED AR-18800-11T",
      "code_information": [
        {
          "code": "3602495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-5 MREYE G36405",
      "code_information": [
        {
          "code": "3602688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-3 MREYE G42419",
      "code_information": [
        {
          "code": "3602689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3602820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 3189.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G BVL 0306-331-000",
      "code_information": [
        {
          "code": "3603302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1474.2211,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE -.9MM AR-7524C",
      "code_information": [
        {
          "code": "3604464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 980.4043,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DBL 4X30/10 PAL-405LL",
      "code_information": [
        {
          "code": "3604617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-8x30/8 PAL-402LL",
      "code_information": [
        {
          "code": "3604619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 597.5414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY METER ALL P4PxxULD",
      "code_information": [
        {
          "code": "3084872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 50.049,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8702H",
      "code_information": [
        {
          "code": "3089122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 58.9466,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          JJ31G",
      "code_information": [
        {
          "code": "3089143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C016D",
      "code_information": [
        {
          "code": "3089188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 6-0          1732G",
      "code_information": [
        {
          "code": "3089203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 35.5904,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX41",
      "code_information": [
        {
          "code": "3089216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 60.6149,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J840D",
      "code_information": [
        {
          "code": "3089388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 54.4978,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ9 8.5CM",
      "code_information": [
        {
          "code": "3311077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 47.8246,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PULLEY-OVERDOOR LUM101P",
      "code_information": [
        {
          "code": "3311351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 39.4831,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LTA MADGIC       MAD600",
      "code_information": [
        {
          "code": "3512793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 37.8148,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 J864D",
      "code_information": [
        {
          "code": "3526246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 8X18",
      "code_information": [
        {
          "code": "3526255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 31.1416,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS NEO-L",
      "code_information": [
        {
          "code": "3541327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 30.0294,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH MALE EXTERNAL MECSB01",
      "code_information": [
        {
          "code": "3550510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 33.9221,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 S-14",
      "code_information": [
        {
          "code": "3559177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 37.8148,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2350H",
      "code_information": [
        {
          "code": "3559280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 57.8344,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 1 VCP741D",
      "code_information": [
        {
          "code": "3598416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 45.0441,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NERVE BLOCK 22G HN3S-80",
      "code_information": [
        {
          "code": "3598440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 36.1465,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2LSL",
      "code_information": [
        {
          "code": "3600232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 31.1416,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63445",
      "code_information": [
        {
          "code": "3603067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 55.0539,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE PMITCSG",
      "code_information": [
        {
          "code": "3603191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 41.1514,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-TOUHY BORST W/SIDE ARM",
      "code_information": [
        {
          "code": "1410050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1049.3607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-FEMORAL ANGIO  DYNJP4119",
      "code_information": [
        {
          "code": "1410800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1343.5376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18GX10CM   G01559",
      "code_information": [
        {
          "code": "1410916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-15      G03955",
      "code_information": [
        {
          "code": "1410919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CLOSED NEEDLE  LNGC-2022",
      "code_information": [
        {
          "code": "1495266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 9G EVIVA",
      "code_information": [
        {
          "code": "1495267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SWIVEL PORTEX 625191",
      "code_information": [
        {
          "code": "3002219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT ANT- 1012S",
      "code_information": [
        {
          "code": "3004017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-RANEY SCALP ADULT 20-1037",
      "code_information": [
        {
          "code": "3008833",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 6374.5743,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE       PMI-TC-SG",
      "code_information": [
        {
          "code": "3010072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 306.4111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE FUZZY       FZ624",
      "code_information": [
        {
          "code": "3020107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 4593.9421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LID-COLLECTION DISP    BKC-506",
      "code_information": [
        {
          "code": "3021629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2446.84,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SURGISAFE ABSORB WHITE",
      "code_information": [
        {
          "code": "3029216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-UNIVRSL I AURO DYNJP1050A",
      "code_information": [
        {
          "code": "3029269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 153.4836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 10CM    70890856",
      "code_information": [
        {
          "code": "3029291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-STENT 6FR M0061802011",
      "code_information": [
        {
          "code": "3038668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR MANIFOLD",
      "code_information": [
        {
          "code": "3050023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 5790.1132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 CX21D",
      "code_information": [
        {
          "code": "3058821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1791.7542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TRU               2C4041",
      "code_information": [
        {
          "code": "3079241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1851.2569,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COAG SUCTION      050-005",
      "code_information": [
        {
          "code": "3085551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ELECTROSURGICAL 8\\\"050-010",
      "code_information": [
        {
          "code": "3085595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 860.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX OUTFLOW AQL-111",
      "code_information": [
        {
          "code": "3086104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-3/8\\\"X3/32\\\"X8'     3508S",
      "code_information": [
        {
          "code": "3086137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 CX22D",
      "code_information": [
        {
          "code": "3089700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-AERO          58-79510",
      "code_information": [
        {
          "code": "3284351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHARMBER-HEATER MR290",
      "code_information": [
        {
          "code": "3290069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-DERMABOND MINI",
      "code_information": [
        {
          "code": "3500037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 180.7325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SPIKE PRIMING   101593",
      "code_information": [
        {
          "code": "3500089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1363.0011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-HYPERINFLATION   1/2 LITER",
      "code_information": [
        {
          "code": "3501291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CAPNOLINE 11996-000163",
      "code_information": [
        {
          "code": "3501717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 370.3626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT TALL LF/ALUM 7704",
      "code_information": [
        {
          "code": "3511782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHANNEL ALL JP22xx",
      "code_information": [
        {
          "code": "3512580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 F/PEDS PEDICAP6",
      "code_information": [
        {
          "code": "3512772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL LRG     L-35MM",
      "code_information": [
        {
          "code": "3513122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3514273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1634.934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEEDER-SPECIALNEEDS 80ML 6000S",
      "code_information": [
        {
          "code": "3515912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLD MIC 40M SQ40SK",
      "code_information": [
        {
          "code": "3516131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE ALL SZS     N7s",
      "code_information": [
        {
          "code": "3519400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-KNEE 22\\\"   1220917",
      "code_information": [
        {
          "code": "3519967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7089-0844",
      "code_information": [
        {
          "code": "3526221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP839D",
      "code_information": [
        {
          "code": "3526344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP838",
      "code_information": [
        {
          "code": "3526348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 260.8109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTOR-ADULT INTUBATED AIRWAY",
      "code_information": [
        {
          "code": "3526527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GROMMET-BEVELED VENT 70241350",
      "code_information": [
        {
          "code": "3527288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS INF-L",
      "code_information": [
        {
          "code": "3541326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DELIVER MORGAN LENS MT202",
      "code_information": [
        {
          "code": "3541942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 473.7972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD/IV FLUID WARMER L-70",
      "code_information": [
        {
          "code": "3542396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 150.7031,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM PREMIE N4901",
      "code_information": [
        {
          "code": "3549181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 24 JP-2234",
      "code_information": [
        {
          "code": "3549296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3741.9969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOCKS-TISSUE FLT-010",
      "code_information": [
        {
          "code": "3549777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIRROR-INSPECTION DIABETIC 081",
      "code_information": [
        {
          "code": "3550157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 680.1103,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM INFANT N4902",
      "code_information": [
        {
          "code": "3550255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 534.4121,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVES-SKIL-CARE GERI SM 5669",
      "code_information": [
        {
          "code": "3550329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF LG MDS601LD",
      "code_information": [
        {
          "code": "3550554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE,MERSILINE 4-0 S-2 1779G",
      "code_information": [
        {
          "code": "3550847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 438.2068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT ANES 2L 72\\\"",
      "code_information": [
        {
          "code": "3559130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP774D",
      "code_information": [
        {
          "code": "3559182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 31619.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-UNDER NOSE",
      "code_information": [
        {
          "code": "3559270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 417.075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 15 JP-2228",
      "code_information": [
        {
          "code": "3559392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 19 JP-2230",
      "code_information": [
        {
          "code": "3559393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-HUMIDIFER MR290V",
      "code_information": [
        {
          "code": "3559432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 209.6497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET NEO",
      "code_information": [
        {
          "code": "3559609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 657.8663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         C-017-D",
      "code_information": [
        {
          "code": "3560077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4258705",
      "code_information": [
        {
          "code": "3568756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 211.318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-COBAN 2LAYER         2094",
      "code_information": [
        {
          "code": "3575850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 180.7325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND UNIVERSAL RT/LT LG",
      "code_information": [
        {
          "code": "3580012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIV 9006-00",
      "code_information": [
        {
          "code": "3580022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3598026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MAC",
      "code_information": [
        {
          "code": "3598027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LAPAROSCOPIC STR 2190J",
      "code_information": [
        {
          "code": "3598116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-POLY OVAL SOFT WIRE",
      "code_information": [
        {
          "code": "3598262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ARTHROGRAM DYNJ07425",
      "code_information": [
        {
          "code": "3598354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAG-DISP SUCT 10’ 30-5201",
      "code_information": [
        {
          "code": "3598648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1 VASC1346",
      "code_information": [
        {
          "code": "3598865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/63-74\\\" 1146PP",
      "code_information": [
        {
          "code": "3598976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-NASAL VIP1137380",
      "code_information": [
        {
          "code": "3599139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 149.5909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-NASAL VIP1137381",
      "code_information": [
        {
          "code": "3599142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 483.807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE RENOVARP GIS-29",
      "code_information": [
        {
          "code": "3599229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 17-22CM",
      "code_information": [
        {
          "code": "3599603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 22-25CM",
      "code_information": [
        {
          "code": "3599604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 25-29CM",
      "code_information": [
        {
          "code": "3599605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 29-36CM",
      "code_information": [
        {
          "code": "3599606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 240014",
      "code_information": [
        {
          "code": "3599773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 836.9305,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SSL",
      "code_information": [
        {
          "code": "3600225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1MSL",
      "code_information": [
        {
          "code": "3600226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1LSL",
      "code_information": [
        {
          "code": "3600227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL WIDE EVO1WSL",
      "code_information": [
        {
          "code": "3600228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 132.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2SSL",
      "code_information": [
        {
          "code": "3600230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2MSL",
      "code_information": [
        {
          "code": "3600231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CN 10MM HEX P45-940-0001",
      "code_information": [
        {
          "code": "3600608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 378.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-JTIP .025X33CM",
      "code_information": [
        {
          "code": "3600780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 542.7536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP726D",
      "code_information": [
        {
          "code": "3601389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 696.7933,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SEDLINE RD",
      "code_information": [
        {
          "code": "3601706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMP SENSING 16FR 119216",
      "code_information": [
        {
          "code": "3601726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PREM CS006",
      "code_information": [
        {
          "code": "3601999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 0 VCPP31D",
      "code_information": [
        {
          "code": "3602463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-INSTRUMENT T50106",
      "code_information": [
        {
          "code": "3603056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 12107.9653,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63447",
      "code_information": [
        {
          "code": "3603065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63446",
      "code_information": [
        {
          "code": "3603066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3603332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 7779.839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-BIOPSY ORT 27550ZAG/10",
      "code_information": [
        {
          "code": "3603541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG GOLD NR30001010",
      "code_information": [
        {
          "code": "3603912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NOMOLINE LH AIRWAY ADAPTER",
      "code_information": [
        {
          "code": "3603959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 662.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED W/ PEEP VALVE",
      "code_information": [
        {
          "code": "3603963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADULT W/ PEEP VAL",
      "code_information": [
        {
          "code": "3603964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION C2202",
      "code_information": [
        {
          "code": "3603996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 6010.3288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP840D",
      "code_information": [
        {
          "code": "3604214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 119.5083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 J305H",
      "code_information": [
        {
          "code": "3012910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 27745.4973,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL3-0 27\\\" FS-2",
      "code_information": [
        {
          "code": "3033304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 45.6002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-ETHICON         PCP-20",
      "code_information": [
        {
          "code": "3033960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 831.3695,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUT-PDS 2-0 Z317H",
      "code_information": [
        {
          "code": "3059073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 2682.0703,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VIC 2-0           J317H",
      "code_information": [
        {
          "code": "3088957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J329H",
      "code_information": [
        {
          "code": "3088960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 101.2102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y215H",
      "code_information": [
        {
          "code": "3088973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y214H",
      "code_information": [
        {
          "code": "3088974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-RETENTION 450G",
      "code_information": [
        {
          "code": "3088984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 36\\\"        Z346H",
      "code_information": [
        {
          "code": "3088987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y398H",
      "code_information": [
        {
          "code": "3088989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 59.5027,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J602H",
      "code_information": [
        {
          "code": "3088995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 296.4013,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y346H",
      "code_information": [
        {
          "code": "3088999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL  0         J946G",
      "code_information": [
        {
          "code": "3089001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 97.3175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J603H",
      "code_information": [
        {
          "code": "3089003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J270H",
      "code_information": [
        {
          "code": "3089004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 65.0637,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J341H",
      "code_information": [
        {
          "code": "3089009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 82.3028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J338H",
      "code_information": [
        {
          "code": "3089016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J311H",
      "code_information": [
        {
          "code": "3089021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 91.2004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRL 1        Y341H",
      "code_information": [
        {
          "code": "3089036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y340H",
      "code_information": [
        {
          "code": "3089037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 37.8148,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8425H",
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        {
          "code": "3089050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8424H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8412H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8433H",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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              "payer_name": "Anthem",
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          ]
        }
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      "service_type": "CDM"
    },
    {
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        },
        {
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        }
      ],
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        {
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          ]
        }
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      "service_type": "CDM"
    },
    {
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        },
        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
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    },
    {
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          "code": "0270",
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        }
      ],
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        {
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          ]
        }
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      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          ]
        }
      ],
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    },
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        }
      ],
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
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        },
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        }
      ],
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        {
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        }
      ],
      "standard_charges": [
        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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          ]
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    },
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        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
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          "code": "3089208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 39.4831,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 9.347,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2        X519H",
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        {
          "code": "3089213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X518H",
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        {
          "code": "3089214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0       1674H",
      "code_information": [
        {
          "code": "3089236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 37.8148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1673H",
      "code_information": [
        {
          "code": "3089242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 37.2587,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        627H",
      "code_information": [
        {
          "code": "3089245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z339H",
      "code_information": [
        {
          "code": "3089255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 36.1465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0   Z304H",
      "code_information": [
        {
          "code": "3089260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J442H",
      "code_information": [
        {
          "code": "3089274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 1689H",
      "code_information": [
        {
          "code": "3089276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            SA87G",
      "code_information": [
        {
          "code": "3089277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2          J880T",
      "code_information": [
        {
          "code": "3089278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2          460T",
      "code_information": [
        {
          "code": "3089298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J214H",
      "code_information": [
        {
          "code": "3089329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 144.0299,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J662H",
      "code_information": [
        {
          "code": "3089339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J347H",
      "code_information": [
        {
          "code": "3089347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 106.7712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J335H",
      "code_information": [
        {
          "code": "3089359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X425H",
      "code_information": [
        {
          "code": "3089385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 205.757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z333H",
      "code_information": [
        {
          "code": "3089395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 131.2396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 626H",
      "code_information": [
        {
          "code": "3089409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685H",
      "code_information": [
        {
          "code": "3500610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 166.2739,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    684G",
      "code_information": [
        {
          "code": "3500770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 88.4199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          K872H",
      "code_information": [
        {
          "code": "3501015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 18FR 30CC      266718",
      "code_information": [
        {
          "code": "3507735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 42.8197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 0 PDP340H",
      "code_information": [
        {
          "code": "3526247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 5380.8236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-3-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 42.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-3-0 PLUS",
      "code_information": [
        {
          "code": "3526254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 1 PDP341H",
      "code_information": [
        {
          "code": "3549733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 1474.2211,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 4-0 R633H",
      "code_information": [
        {
          "code": "3549987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 2490.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        635G",
      "code_information": [
        {
          "code": "3555389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           622-H",
      "code_information": [
        {
          "code": "3557329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK O             624H",
      "code_information": [
        {
          "code": "3557386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            K834H",
      "code_information": [
        {
          "code": "3557388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           661-G",
      "code_information": [
        {
          "code": "3557535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           662-G",
      "code_information": [
        {
          "code": "3557568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           663-H",
      "code_information": [
        {
          "code": "3557592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 2.0        664G",
      "code_information": [
        {
          "code": "3557990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON            801H",
      "code_information": [
        {
          "code": "3558467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 47.8246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 3-0        1671-H",
      "code_information": [
        {
          "code": "3559001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 580.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         B-842-H",
      "code_information": [
        {
          "code": "3560064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH CHROMIC 3-0 G-122-H",
      "code_information": [
        {
          "code": "3560211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J219H",
      "code_information": [
        {
          "code": "3560487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J258H",
      "code_information": [
        {
          "code": "3560490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-259-H",
      "code_information": [
        {
          "code": "3560505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL          J-416-H",
      "code_information": [
        {
          "code": "3560745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 46.1563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J415H",
      "code_information": [
        {
          "code": "3560840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 32.8099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J417H",
      "code_information": [
        {
          "code": "3561410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        669H",
      "code_information": [
        {
          "code": "3561418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 3-0  J-944-H",
      "code_information": [
        {
          "code": "3561419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-832-H",
      "code_information": [
        {
          "code": "3561461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-833-H",
      "code_information": [
        {
          "code": "3561495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 37.8148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH MONOCRL 2-0   Y259H",
      "code_information": [
        {
          "code": "3562109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 51.1612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3.0    Y-338-H",
      "code_information": [
        {
          "code": "3562123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y416H",
      "code_information": [
        {
          "code": "3562126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0     H822H",
      "code_information": [
        {
          "code": "3562128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 55.0539,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 FS-1    1629H",
      "code_information": [
        {
          "code": "3562140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 22.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8683G",
      "code_information": [
        {
          "code": "3562227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 47.8246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           683G",
      "code_information": [
        {
          "code": "3562240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K871H",
      "code_information": [
        {
          "code": "3562245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 71.1808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP316H",
      "code_information": [
        {
          "code": "3598241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP945G",
      "code_information": [
        {
          "code": "3598400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 J422H",
      "code_information": [
        {
          "code": "3598401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL SZ 1 36\\\" J519H",
      "code_information": [
        {
          "code": "3598406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS #1 VCP371H",
      "code_information": [
        {
          "code": "3598411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 58.9466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 G181H",
      "code_information": [
        {
          "code": "3598414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1670H",
      "code_information": [
        {
          "code": "3598421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 2-0 VCP195H",
      "code_information": [
        {
          "code": "3598422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ #1 VCP569H",
      "code_information": [
        {
          "code": "3598423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 4.0 VCP310H",
      "code_information": [
        {
          "code": "3598433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 32.2538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0 664H",
      "code_information": [
        {
          "code": "3598435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 J306H",
      "code_information": [
        {
          "code": "3598715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 4768.0014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP311H",
      "code_information": [
        {
          "code": "3602123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 116.2249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 663G",
      "code_information": [
        {
          "code": "3602506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 2-0 MCP345H",
      "code_information": [
        {
          "code": "3602920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 4266.3992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0   Y303H",
      "code_information": [
        {
          "code": "3603113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 90.6443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 VCP602H",
      "code_information": [
        {
          "code": "3603514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP305H",
      "code_information": [
        {
          "code": "3604136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 161.8251,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP422H",
      "code_information": [
        {
          "code": "3604226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 8281.4412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP218H",
      "code_information": [
        {
          "code": "3604353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 5822.367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 4-0 VCP434H",
      "code_information": [
        {
          "code": "3604548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 199.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 9.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT         PI-104",
      "code_information": [
        {
          "code": "3019880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 55.0539,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 2xFR",
      "code_information": [
        {
          "code": "3058922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 44.488,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 16\\\" 7716-000-10",
      "code_information": [
        {
          "code": "3060133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 56.1661,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNELER 16G     ACC10S",
      "code_information": [
        {
          "code": "3079464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 76.7418,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SEPTAL NEIMAN  14-0441",
      "code_information": [
        {
          "code": "3080203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 67.8442,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMDxx40x",
      "code_information": [
        {
          "code": "3082490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 38.927,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-EYE 10.0          7711G",
      "code_information": [
        {
          "code": "3082557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 35.5904,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXMP1B117",
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        {
          "code": "3089421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 99.5419,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 3.2MM        702462",
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        {
          "code": "3091254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 99.5419,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBIGRIP D 1437",
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        {
          "code": "3503055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 105.1029,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH X3-003-000",
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        {
          "code": "3504921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 93.9809,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 600ML 622278",
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        {
          "code": "3505722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 57.8344,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC FREEDOM 300ML",
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        {
          "code": "3506124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 47.8246,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CRITICORE URINARY  900216",
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        {
          "code": "3506760",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 94.537,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC ALL SZ",
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        {
          "code": "3510098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 107.8834,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYLOG 3000 DISPOSABLE",
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        {
          "code": "3510130",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 80.0784,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COLLECTN BREAST MILK  67's",
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        {
          "code": "3521700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 40.0392,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSORMAT-CHAIR-CHEC 65815-030",
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        {
          "code": "3541322",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 5FR TMI      1154",
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        {
          "code": "3541914",
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR A3",
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        {
          "code": "3550415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 101.7663,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION A495LM",
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        {
          "code": "3559184",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PROCEDURE PICC W/O PICC",
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        {
          "code": "3570790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 102.3224,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 18GA    9001C0212",
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        {
          "code": "3590035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 62.8393,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-POLAR KNEE WRAP-ON",
      "code_information": [
        {
          "code": "3598080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 96.7614,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BONE MARROW 11GX4\\\" BAK451",
      "code_information": [
        {
          "code": "3598402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 35.5904,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM BLADED CTB73",
      "code_information": [
        {
          "code": "3598438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 60.6149,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL EVF1XMLSLA",
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        {
          "code": "3600224",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 99.5419,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADS-LACURA VISCO FOOT",
      "code_information": [
        {
          "code": "3604310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 71.1808,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 7FR       06-107F",
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        {
          "code": "1415875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 MS-DC5020",
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        {
          "code": "3002250",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          MS-DC28",
      "code_information": [
        {
          "code": "3002372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DERMATOME 00-8800-000-10",
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        {
          "code": "3002650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-7.3 ARCH AORTIC MT022A",
      "code_information": [
        {
          "code": "3004031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHOULDER ALL AR-6500s",
      "code_information": [
        {
          "code": "3004216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS HIFLO 24F 69324",
      "code_information": [
        {
          "code": "3004482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR        12002",
      "code_information": [
        {
          "code": "3004521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 898.1015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-5MM PROT BLUE 5027-1050",
      "code_information": [
        {
          "code": "3004650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 809.6816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-34 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-42 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 17613.3553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-UTERINE MANIPULATOR",
      "code_information": [
        {
          "code": "3019600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MAGNUM BIOPSY    MN18xx",
      "code_information": [
        {
          "code": "3027515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 442.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-PERI-OB DRAPE       2997",
      "code_information": [
        {
          "code": "3034345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-CANNULA XI      470381",
      "code_information": [
        {
          "code": "3039883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 466.0118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-SUTURE ASSISTANT  SW110",
      "code_information": [
        {
          "code": "3039900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 479.3582,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETAINER-VISCERA LARGE HS-3206",
      "code_information": [
        {
          "code": "3040486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 BV-1 BLUE EPH9702H",
      "code_information": [
        {
          "code": "3058802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 44501.9025,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL NEW",
      "code_information": [
        {
          "code": "3059210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN",
      "code_information": [
        {
          "code": "3059265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2961.2325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-VIA-GUARD SMP-2006-001",
      "code_information": [
        {
          "code": "3060015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 519.9535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THREADED 72200425",
      "code_information": [
        {
          "code": "3060484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 741.8374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-ELECTROLUBE         EL101",
      "code_information": [
        {
          "code": "3078867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 697.3494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING           031229-10",
      "code_information": [
        {
          "code": "3079239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-IRRIG SUCT 250070530",
      "code_information": [
        {
          "code": "3083086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 45CM     3909",
      "code_information": [
        {
          "code": "3083636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-ONQ ALL         T1X's",
      "code_information": [
        {
          "code": "3086215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS ADAPTER",
      "code_information": [
        {
          "code": "3087517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 1010030",
      "code_information": [
        {
          "code": "3088591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 300.8501,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 5        RS21",
      "code_information": [
        {
          "code": "3089261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 337.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-BLUE VLOCN0615",
      "code_information": [
        {
          "code": "3089401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             1101",
      "code_information": [
        {
          "code": "3093210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1368.5621,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS 420023",
      "code_information": [
        {
          "code": "3155010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS LONG",
      "code_information": [
        {
          "code": "3155020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION ADJ",
      "code_information": [
        {
          "code": "3311604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD           KVL03",
      "code_information": [
        {
          "code": "3504920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 1L    622283",
      "code_information": [
        {
          "code": "3505720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE A ARTERIAL    400115A",
      "code_information": [
        {
          "code": "3521984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 280.8305,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-KIWI OMNI SYSTEM",
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        {
          "code": "3522453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 650.0809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22G X 20CM",
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        {
          "code": "3526117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PULSAVAC IRRIGATION",
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        {
          "code": "3526128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 44501.9025,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CYSTO           DYNJ49183",
      "code_information": [
        {
          "code": "3526166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-KENNEDY SINUS      400426",
      "code_information": [
        {
          "code": "3526168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 9787.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 30 SXPP1B410",
      "code_information": [
        {
          "code": "3526382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 34 DPSB 60707010600",
      "code_information": [
        {
          "code": "3526496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1082.7267,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMD2B401",
      "code_information": [
        {
          "code": "3526937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-HEEL SUSPENSION   M60-300",
      "code_information": [
        {
          "code": "3528097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 528.295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 42 DPSB 60707010700",
      "code_information": [
        {
          "code": "3529497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ZONE NAVIGATOR AR790x",
      "code_information": [
        {
          "code": "3547988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K OLIVE 2MM 703818",
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        {
          "code": "3549171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAGITTAL 40X14X0.6",
      "code_information": [
        {
          "code": "3549447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 5MM 0227-010-250",
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        {
          "code": "3549930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-INTRACK ULTRA 66MM",
      "code_information": [
        {
          "code": "3550346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-C1/T1/MR1 EXPIRATORY 161",
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        {
          "code": "3550566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-COAXIAL BREATHING DISP",
      "code_information": [
        {
          "code": "3550567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 774.0912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-WHEELCHAIR MEDIUM 565613",
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        {
          "code": "3550733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE",
      "code_information": [
        {
          "code": "3550798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 959.8286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.25X200MM A-5040.30/1",
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        {
          "code": "3550826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DELUXE KNEE/HIP 081603273",
      "code_information": [
        {
          "code": "3550839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4881.4458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTERPULSE HANDLE W TIP",
      "code_information": [
        {
          "code": "3550870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 12MM ONB12STF",
      "code_information": [
        {
          "code": "3559126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AF541",
      "code_information": [
        {
          "code": "3559226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 6901.201,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ4",
      "code_information": [
        {
          "code": "3559252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URI-CATH 3.5FR&5.0FR",
      "code_information": [
        {
          "code": "3566802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF 7.0MM",
      "code_information": [
        {
          "code": "3573939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 625.6125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 8.0MM",
      "code_information": [
        {
          "code": "3590138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 15' 251015J",
      "code_information": [
        {
          "code": "3598139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4336.4678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMP2B401",
      "code_information": [
        {
          "code": "3598157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 6183.2759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER PAD F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 539.9731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH 5FR TMI1185",
      "code_information": [
        {
          "code": "3598221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 21028.3654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSPAC TRIFURCATED 42800",
      "code_information": [
        {
          "code": "3598244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 331.9917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4X70/16MM 607470",
      "code_information": [
        {
          "code": "3598460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 314.7526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 GORE-TEX 4N10B",
      "code_information": [
        {
          "code": "3598958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1007.6532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 18 FR",
      "code_information": [
        {
          "code": "3599116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 16 FR",
      "code_information": [
        {
          "code": "3599117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-NITINOL PILOT 5901-6072",
      "code_information": [
        {
          "code": "3599187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/25CM MN1825",
      "code_information": [
        {
          "code": "3599317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4392.0778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSIONS-CABLE DISP 4051L",
      "code_information": [
        {
          "code": "3599647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4002.8078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.1CM",
      "code_information": [
        {
          "code": "3600164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 336.4405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.6X150MM P99-292-1615",
      "code_information": [
        {
          "code": "3600326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 900.3259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-CAPTURA DISP G53006",
      "code_information": [
        {
          "code": "3600504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 989.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-192-2330",
      "code_information": [
        {
          "code": "3600521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TENNIS RACQUET 5FR/90CM",
      "code_information": [
        {
          "code": "3600554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 989.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ 3",
      "code_information": [
        {
          "code": "3600778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 28621.9109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-2.0X200MM P99-192-2020",
      "code_information": [
        {
          "code": "3601106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1091.6243,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,GASTRO MIC",
      "code_information": [
        {
          "code": "3601451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 876.9697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MIAR 14G 7FR 11014L",
      "code_information": [
        {
          "code": "3601478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 283.611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-OSIA OSI200 P1291019",
      "code_information": [
        {
          "code": "3601610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300 NTHRD 702463",
      "code_information": [
        {
          "code": "3601870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-193-2323",
      "code_information": [
        {
          "code": "3602140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.1MM AR-8655K-11",
      "code_information": [
        {
          "code": "3602154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SHEATH W/CATH SA-09847",
      "code_information": [
        {
          "code": "3602436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PT PUMP 8\\\"\\\" AR-6421",
      "code_information": [
        {
          "code": "3602461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2892.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-RING 16\\\" DUR8016W",
      "code_information": [
        {
          "code": "3602526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.2X150 TH P99-193-1215",
      "code_information": [
        {
          "code": "3602570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP TRB29-LRG",
      "code_information": [
        {
          "code": "3602758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.0X200MM P99-193-2020",
      "code_information": [
        {
          "code": "3602993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 877.5258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X100MM P99-192-1410",
      "code_information": [
        {
          "code": "3603370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-BIVENTRICULAR BS-101-97",
      "code_information": [
        {
          "code": "3603546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 3-0 PS-2",
      "code_information": [
        {
          "code": "3603921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.4X15 MSG14150",
      "code_information": [
        {
          "code": "3604046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.6X15 MSG16150",
      "code_information": [
        {
          "code": "3604056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 7516.2476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X150MM P99-292-0915",
      "code_information": [
        {
          "code": "3604177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X150 SM P99-192-2315",
      "code_information": [
        {
          "code": "3604181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-292-1115",
      "code_information": [
        {
          "code": "3604182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1615",
      "code_information": [
        {
          "code": "3604183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1415",
      "code_information": [
        {
          "code": "3604184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-U-FRAME STRD MT-APU-2.4",
      "code_information": [
        {
          "code": "3604229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 868.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-HEX 10MM 76-10185",
      "code_information": [
        {
          "code": "3604312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-GUARDIAN HEMOSTAT 8215",
      "code_information": [
        {
          "code": "3604336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 519.3974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-WASTE 04369",
      "code_information": [
        {
          "code": "3604367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 7227.6317,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K .9X150MM P99-192-0915",
      "code_information": [
        {
          "code": "3604377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG 900-152",
      "code_information": [
        {
          "code": "3604585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD-EX 900-154",
      "code_information": [
        {
          "code": "3604586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD 900-151",
      "code_information": [
        {
          "code": "3604587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG-SHL 900-155",
      "code_information": [
        {
          "code": "3604588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FINGER SMALL 9906",
      "code_information": [
        {
          "code": "3604630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 249.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONTROLLER-AZUR DETACH 45-4001",
      "code_information": [
        {
          "code": "1411129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FUNNEL-KELLER 2 HA-005",
      "code_information": [
        {
          "code": "3000004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 3FR 0   390-103",
      "code_information": [
        {
          "code": "3002153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-STONE 1.9FR     390-105",
      "code_information": [
        {
          "code": "3002162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-1.3F NITINOL STONE",
      "code_information": [
        {
          "code": "3002170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIPOFILTER-ASP CAN 25",
      "code_information": [
        {
          "code": "3002211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 2.0",
      "code_information": [
        {
          "code": "3002254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLUTED 4.0MM  315.40",
      "code_information": [
        {
          "code": "3002335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0          357.407",
      "code_information": [
        {
          "code": "3002356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TIB DRILL 195MM     315.29",
      "code_information": [
        {
          "code": "3002367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 PERIPH SCREW",
      "code_information": [
        {
          "code": "3002369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM     03.617.9xx",
      "code_information": [
        {
          "code": "3002371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5",
      "code_information": [
        {
          "code": "3002374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X230   1806-35xxS",
      "code_information": [
        {
          "code": "3002378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        72-2011",
      "code_information": [
        {
          "code": "3002384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 324.214",
      "code_information": [
        {
          "code": "3002392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM 702453",
      "code_information": [
        {
          "code": "3002396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8737-09",
      "code_information": [
        {
          "code": "3002398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 255589000",
      "code_information": [
        {
          "code": "3002401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.0 SCREW DRIVER",
      "code_information": [
        {
          "code": "3002656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1xMM 2868-20-01x",
      "code_information": [
        {
          "code": "3002771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              316.286",
      "code_information": [
        {
          "code": "3002781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SIZES     703xxx",
      "code_information": [
        {
          "code": "3002789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT ALL    18-84004HR",
      "code_information": [
        {
          "code": "3003228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT 2.9MM    18-82904",
      "code_information": [
        {
          "code": "3003237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER     62-27015",
      "code_information": [
        {
          "code": "3003253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO              CYB-x",
      "code_information": [
        {
          "code": "3003505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION xMM 5820-009-0xx",
      "code_information": [
        {
          "code": "3003845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 29FR 96370-029",
      "code_information": [
        {
          "code": "3004237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 10M OMS-T10BT",
      "code_information": [
        {
          "code": "3005080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-OMEGA        1004930",
      "code_information": [
        {
          "code": "3009748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ENDO LINEAR       ATS45",
      "code_information": [
        {
          "code": "3009970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACCESS 10 GAUGE",
      "code_information": [
        {
          "code": "3012102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SKYLINE 14MM   286820014",
      "code_information": [
        {
          "code": "3012132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SZ   2883-01-xxx",
      "code_information": [
        {
          "code": "3012205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-PERCUTANEOUS DRILL 324.213",
      "code_information": [
        {
          "code": "3012223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0          323.062",
      "code_information": [
        {
          "code": "3012319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          80-0387",
      "code_information": [
        {
          "code": "3012332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.103",
      "code_information": [
        {
          "code": "3012342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.50x",
      "code_information": [
        {
          "code": "3012358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T7 TORX 703665",
      "code_information": [
        {
          "code": "3012408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 4CHAN 8227411",
      "code_information": [
        {
          "code": "3012587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-ROLLER 24FR WA22038C",
      "code_information": [
        {
          "code": "3012594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING 3.5FR  370-115",
      "code_information": [
        {
          "code": "3013315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-EXTRA STRENGTH GRASPING",
      "code_information": [
        {
          "code": "3013324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE BLUNT 2867-05-220",
      "code_information": [
        {
          "code": "3016132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERTER-SCREW T8   03.617.904",
      "code_information": [
        {
          "code": "3019821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE   28164Mx/3",
      "code_information": [
        {
          "code": "3019825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACIUM 30 CM TUNNELING TOOL",
      "code_information": [
        {
          "code": "3019908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CTR INDIANA TOME  200060",
      "code_information": [
        {
          "code": "3021156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONETTED       3101055",
      "code_information": [
        {
          "code": "3021160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KOH ALL",
      "code_information": [
        {
          "code": "3022136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STR COLD KNIFE K-SB",
      "code_information": [
        {
          "code": "3022228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MULTIFIRE SCORPION",
      "code_information": [
        {
          "code": "3027390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 11M VS101011P",
      "code_information": [
        {
          "code": "3027592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM EYE WENTWORTH",
      "code_information": [
        {
          "code": "3029171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CARTER/MOORE      7959E",
      "code_information": [
        {
          "code": "3029197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "QFIX-DISP SHOULDER 2.8MM",
      "code_information": [
        {
          "code": "3029223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASOPORE  5400-020-008",
      "code_information": [
        {
          "code": "3029293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE RGLR",
      "code_information": [
        {
          "code": "3029340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE XL",
      "code_information": [
        {
          "code": "3029342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-SCREW GUIDE      230790004",
      "code_information": [
        {
          "code": "3030620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STRT 302-431-000",
      "code_information": [
        {
          "code": "3034513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE0-FIAPC CIRCUMFRENTIAL",
      "code_information": [
        {
          "code": "3034521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PNEUMATIC ALL SZ  840-7s",
      "code_information": [
        {
          "code": "3034527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PRASS FLUSH TIP  8225101",
      "code_information": [
        {
          "code": "3034535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICLE SCREW    9450019",
      "code_information": [
        {
          "code": "3034581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-ANASTOCLIP 4001-00",
      "code_information": [
        {
          "code": "3039801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GRAY     ECR45M",
      "code_information": [
        {
          "code": "3039879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60W       GST60W",
      "code_information": [
        {
          "code": "3039929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60T GST60T",
      "code_information": [
        {
          "code": "3039946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3040420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.0 CANN DRI",
      "code_information": [
        {
          "code": "3040703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-SHORT BEVEL 35",
      "code_information": [
        {
          "code": "3058621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 3.0MM",
      "code_information": [
        {
          "code": "3058676",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SM JOINT 2.4MM DRILL&GUID",
      "code_information": [
        {
          "code": "3058763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6MM AR 8943-02",
      "code_information": [
        {
          "code": "3058783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL CONICAL 3+4MM",
      "code_information": [
        {
          "code": "3058870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL WIDENING xMM",
      "code_information": [
        {
          "code": "3058871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED",
      "code_information": [
        {
          "code": "3058948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM xxMM JLATC",
      "code_information": [
        {
          "code": "3059041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-HCS xxMM",
      "code_information": [
        {
          "code": "3059042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR 200-120",
      "code_information": [
        {
          "code": "3059077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 4.3MM",
      "code_information": [
        {
          "code": "3059085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM XFO130022",
      "code_information": [
        {
          "code": "3059096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 15CMX2.2MM 15MH22",
      "code_information": [
        {
          "code": "3059107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X216MM SHORT",
      "code_information": [
        {
          "code": "3059144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X216MM SHORT",
      "code_information": [
        {
          "code": "3059146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTASIS RESOLUTION 36",
      "code_information": [
        {
          "code": "3059208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE GST45W",
      "code_information": [
        {
          "code": "3059268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST45B",
      "code_information": [
        {
          "code": "3059269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45GREEN GST45G",
      "code_information": [
        {
          "code": "3059276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60BLUE GST60B",
      "code_information": [
        {
          "code": "3059280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL MN60MA 00.0",
      "code_information": [
        {
          "code": "3060419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE DISP FIRSTPASS",
      "code_information": [
        {
          "code": "3060480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAGITTAL STD 116170",
      "code_information": [
        {
          "code": "3060497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAG NARROW 116171",
      "code_information": [
        {
          "code": "3060498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5",
      "code_information": [
        {
          "code": "3069109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER MOD.TRINKLE",
      "code_information": [
        {
          "code": "3079260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3081128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE WHITE VASECR35",
      "code_information": [
        {
          "code": "3081553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PUSHLOCK 2.9  AR-1923DS",
      "code_information": [
        {
          "code": "3083078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI SLEEVE 32F 5232B",
      "code_information": [
        {
          "code": "3083150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PROGEL EXTENDED PGEN005-06",
      "code_information": [
        {
          "code": "3083771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-MIDAS LEGEND ALL 14BAxxDC",
      "code_information": [
        {
          "code": "3084380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM         14MH30",
      "code_information": [
        {
          "code": "3084589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 8",
      "code_information": [
        {
          "code": "3084826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT INSTRUM 9733533XOM",
      "code_information": [
        {
          "code": "3084911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT PATIENT",
      "code_information": [
        {
          "code": "3084948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL LONG 5MM      B5XT",
      "code_information": [
        {
          "code": "3085206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12MM         B12LT",
      "code_information": [
        {
          "code": "3085209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 7.5FR MEGA IAB",
      "code_information": [
        {
          "code": "3085536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DISP INSTRUMENT MINI S-TAK",
      "code_information": [
        {
          "code": "3085539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-EXCEL LONG 12MM   B12XT",
      "code_information": [
        {
          "code": "3085625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON         1806-0073S",
      "code_information": [
        {
          "code": "3085870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST60G",
      "code_information": [
        {
          "code": "3086960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6 703702",
      "code_information": [
        {
          "code": "3087918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TWIST DRILL 2.3 72203160",
      "code_information": [
        {
          "code": "3087938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRPAE 3-ARM S.I.E.  420290",
      "code_information": [
        {
          "code": "3139015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 BLUE XI",
      "code_information": [
        {
          "code": "3186035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 GREEN XI",
      "code_information": [
        {
          "code": "3186037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRST 45 WHTE 48645W",
      "code_information": [
        {
          "code": "3186041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-EPISTAT XOMED    15-27031",
      "code_information": [
        {
          "code": "3507977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HELMET-PROTECTIVE SOFT A8000",
      "code_information": [
        {
          "code": "3519273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM 8MM JLATCH",
      "code_information": [
        {
          "code": "3526157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 102MM X 11GA",
      "code_information": [
        {
          "code": "3526202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 152MM X 11GA",
      "code_information": [
        {
          "code": "3526203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO MEASURING 2.0X110MM",
      "code_information": [
        {
          "code": "3526234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-SURGICAL POWDER",
      "code_information": [
        {
          "code": "3526249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO LONG 2.4X140MM",
      "code_information": [
        {
          "code": "3526301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE A0 XTV008001",
      "code_information": [
        {
          "code": "3526333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-COMPLEX BREAST DYNJ60133",
      "code_information": [
        {
          "code": "3526421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC XI DYNJ905698",
      "code_information": [
        {
          "code": "3526424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-NEURO DYNJ60135",
      "code_information": [
        {
          "code": "3526427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW CANN HEX 2.5MM",
      "code_information": [
        {
          "code": "3526498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ASSIST CUSTOM BB10M33R",
      "code_information": [
        {
          "code": "3526535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BARIATRIC DYNJ52366",
      "code_information": [
        {
          "code": "3526671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-PURGE 043-0003",
      "code_information": [
        {
          "code": "3526914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION KNEE AR-12990",
      "code_information": [
        {
          "code": "3526976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EUS 19GA",
      "code_information": [
        {
          "code": "3526981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN DRILL 3.0X170MM 70535",
      "code_information": [
        {
          "code": "3526990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER TORX 703667",
      "code_information": [
        {
          "code": "3527081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST PLEUREVAC A-9250LF",
      "code_information": [
        {
          "code": "3527083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.4X150MM 702448",
      "code_information": [
        {
          "code": "3527149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-MICROBLATOR 30 AC4050-01",
      "code_information": [
        {
          "code": "3527275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3527286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM WHITE 47630W",
      "code_information": [
        {
          "code": "3527881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM BLUE 48630B",
      "code_information": [
        {
          "code": "3527882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN 48630G",
      "code_information": [
        {
          "code": "3527883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-PLASMA STERILE   015",
      "code_information": [
        {
          "code": "3541330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTRODUCER LOCALIZATION",
      "code_information": [
        {
          "code": "3542520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANNULATED 5.0 705361",
      "code_information": [
        {
          "code": "3547933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLACK GST45T",
      "code_information": [
        {
          "code": "3548010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION",
      "code_information": [
        {
          "code": "3549013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION 14FR",
      "code_information": [
        {
          "code": "3549014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 0210",
      "code_information": [
        {
          "code": "3549040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON 50 PASSPORT",
      "code_information": [
        {
          "code": "3549108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6X135MM 703691",
      "code_information": [
        {
          "code": "3549125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.0X135MM 703690",
      "code_information": [
        {
          "code": "3549128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 2.7X122MM 703695",
      "code_information": [
        {
          "code": "3549129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703880",
      "code_information": [
        {
          "code": "3549137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP-50",
      "code_information": [
        {
          "code": "3549153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANN 3.0MM",
      "code_information": [
        {
          "code": "3549162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TORFLEX GUIDING",
      "code_information": [
        {
          "code": "3549175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL HEARTSPAN",
      "code_information": [
        {
          "code": "3549177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP",
      "code_information": [
        {
          "code": "3549202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-BLADE 45-35015",
      "code_information": [
        {
          "code": "3549235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 703896",
      "code_information": [
        {
          "code": "3549240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL 10ML TWIN PK",
      "code_information": [
        {
          "code": "3549261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X230MM 700355",
      "code_information": [
        {
          "code": "3549276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ATSV II BE 8025H",
      "code_information": [
        {
          "code": "3549306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM CANN AR-1218-40",
      "code_information": [
        {
          "code": "3549308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PROFILE AR-1410LP",
      "code_information": [
        {
          "code": "3549310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3549410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACC-SELECTRA IC 50 392290",
      "code_information": [
        {
          "code": "3549414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-3.5 CAN DRILL AR-8956-35P",
      "code_information": [
        {
          "code": "3549430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X122MM 703897",
      "code_information": [
        {
          "code": "3549436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL J-HATCH 14MM",
      "code_information": [
        {
          "code": "3549445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 3.0MM",
      "code_information": [
        {
          "code": "3549453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MINI SUTURE 72290128",
      "code_information": [
        {
          "code": "3549714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SHAFT CANN 6192.0040",
      "code_information": [
        {
          "code": "3549723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 3.5X122MM 703694",
      "code_information": [
        {
          "code": "3549799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3549806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 3.2 X 216 705",
      "code_information": [
        {
          "code": "3549843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 4.3X216 705043",
      "code_information": [
        {
          "code": "3549844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T8 TORX AO 703663",
      "code_information": [
        {
          "code": "3549847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAGNET-REPLACEMENT COCHLEAR",
      "code_information": [
        {
          "code": "3549900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.4X122MM 703696",
      "code_information": [
        {
          "code": "3549904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PILOTED 6.0MM AR-1450",
      "code_information": [
        {
          "code": "3550002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANNU STR",
      "code_information": [
        {
          "code": "3550047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145 03.010.104",
      "code_information": [
        {
          "code": "3550057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-TENSIONER AR-5815",
      "code_information": [
        {
          "code": "3550191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR ACCESS 21030",
      "code_information": [
        {
          "code": "3550197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GJ 22 FR FEEDING 8660-22",
      "code_information": [
        {
          "code": "3550289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563010",
      "code_information": [
        {
          "code": "3550451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563020",
      "code_information": [
        {
          "code": "3550452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563030",
      "code_information": [
        {
          "code": "3550453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563040",
      "code_information": [
        {
          "code": "3550454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASCOPE-RHINOLARYNGO SLIM 51000",
      "code_information": [
        {
          "code": "3550507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERC INSERT AR-1923PK",
      "code_information": [
        {
          "code": "3550583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP 3 BAG SPIKE BLOOD IV",
      "code_information": [
        {
          "code": "3550718",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2009",
      "code_information": [
        {
          "code": "3550763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-910-3500",
      "code_information": [
        {
          "code": "3550772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.6X130MM P99-110-2613",
      "code_information": [
        {
          "code": "3550773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STIM 2862-02-203",
      "code_information": [
        {
          "code": "3550853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4X195MM ST 315.40S",
      "code_information": [
        {
          "code": "3550855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-INFUSION 8FR BIOFLO H787C",
      "code_information": [
        {
          "code": "3550906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.3X100MM P99-100-1310",
      "code_information": [
        {
          "code": "3559004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STERNAL 99-006-01-04",
      "code_information": [
        {
          "code": "3559018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO RESOLUTION 360",
      "code_information": [
        {
          "code": "3559020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENFIT GJ FEEDING 18X45 825",
      "code_information": [
        {
          "code": "3559086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X12MM VASC SIG30TAV",
      "code_information": [
        {
          "code": "3559124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-VAS",
      "code_information": [
        {
          "code": "3559125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 2.3X120MM",
      "code_information": [
        {
          "code": "3559139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN W/AO 2.7MM 705250",
      "code_information": [
        {
          "code": "3559186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 16FR 98437",
      "code_information": [
        {
          "code": "3559429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15X45 XT SIG45AXT",
      "code_information": [
        {
          "code": "3559637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LARYNGOSCOPE-CMOS IDEO RHINO",
      "code_information": [
        {
          "code": "3559674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL VERACROSS",
      "code_information": [
        {
          "code": "3559675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-NAVIGATION TDNC001",
      "code_information": [
        {
          "code": "3559689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM AR-8737-34",
      "code_information": [
        {
          "code": "3598007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PASS STIM DM-8225101",
      "code_information": [
        {
          "code": "3598049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE DBL ABS-10010S",
      "code_information": [
        {
          "code": "3598066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACP+ACD-A ABS-10011T",
      "code_information": [
        {
          "code": "3598067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-14CC MIX ABS-2000",
      "code_information": [
        {
          "code": "3598068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5F 007250P",
      "code_information": [
        {
          "code": "3598088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y-SHAPE SHUNT FV015T",
      "code_information": [
        {
          "code": "3598131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8737-35",
      "code_information": [
        {
          "code": "3598175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI FT CMP AR-8737-41",
      "code_information": [
        {
          "code": "3598177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HOOK/TRI BLADE 2056-6",
      "code_information": [
        {
          "code": "3598195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-915-3500",
      "code_information": [
        {
          "code": "3598232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X60MM 58850025",
      "code_information": [
        {
          "code": "3598253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5.5X60MM 58850055",
      "code_information": [
        {
          "code": "3598254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SCALED 2X150MM 705134",
      "code_information": [
        {
          "code": "3598286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T TRACH SZ10 LT-510-S",
      "code_information": [
        {
          "code": "3598307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-MINIONE M1-1-1824",
      "code_information": [
        {
          "code": "3598321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE SG CTI-10155G",
      "code_information": [
        {
          "code": "3598399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TI-KNOT 5MM 030404",
      "code_information": [
        {
          "code": "3598526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X14MM 03.617.914",
      "code_information": [
        {
          "code": "3598581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X24MM 58850020",
      "code_information": [
        {
          "code": "3598638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY",
      "code_information": [
        {
          "code": "3598673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45",
      "code_information": [
        {
          "code": "3598675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM AR-8737-58",
      "code_information": [
        {
          "code": "3598691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.6 CANN AR-8741-32",
      "code_information": [
        {
          "code": "3598694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT4.0 CA DRILL AR-8956C-40PD",
      "code_information": [
        {
          "code": "3598808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T25 PERIP 5901-1128",
      "code_information": [
        {
          "code": "3599025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 32FR 5532S",
      "code_information": [
        {
          "code": "3599075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 40FR 5540B",
      "code_information": [
        {
          "code": "3599076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8X200MM 03.133.108",
      "code_information": [
        {
          "code": "3599159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/110X30MM 03.133.100",
      "code_information": [
        {
          "code": "3599236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/140X60MM 03.133.101",
      "code_information": [
        {
          "code": "3599240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/170X80 03.133.107",
      "code_information": [
        {
          "code": "3599241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/170X80 03.133.103",
      "code_information": [
        {
          "code": "3599255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X60MM 58850028",
      "code_information": [
        {
          "code": "3599257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 4.2X120 P99-100-421",
      "code_information": [
        {
          "code": "3599394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X130 1806-3550S",
      "code_information": [
        {
          "code": "3599470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-CANN 4MM 705260",
      "code_information": [
        {
          "code": "3599495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.012",
      "code_information": [
        {
          "code": "3599540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TALAR PEG 4MM IB200020",
      "code_information": [
        {
          "code": "3599675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVR 3.5X110 P99-110-3511",
      "code_information": [
        {
          "code": "3599772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STERILE PERC 150MM 9733236",
      "code_information": [
        {
          "code": "3599775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 2MM MR8-15MH22",
      "code_information": [
        {
          "code": "3599776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM MR8-14MH30",
      "code_information": [
        {
          "code": "3599777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 545CC SSZ-X545",
      "code_information": [
        {
          "code": "3599822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 485CC SSZ-F485",
      "code_information": [
        {
          "code": "3599823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 365CC SSZ-F365",
      "code_information": [
        {
          "code": "3599824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 400CC SSZ-X400",
      "code_information": [
        {
          "code": "3599825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BONE BIOPSY CD1110",
      "code_information": [
        {
          "code": "3599838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT DPT5",
      "code_information": [
        {
          "code": "3599926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM AR-18800-19",
      "code_information": [
        {
          "code": "3600284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3X100 MWM100",
      "code_information": [
        {
          "code": "3600385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 3.5X160 P99-110-3516",
      "code_information": [
        {
          "code": "3600392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-NANO 125MM AR-3210-0053",
      "code_information": [
        {
          "code": "3600399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3600410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM SHRT AR-18800-18",
      "code_information": [
        {
          "code": "3600411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CN 2MM AR-8610DB-30C",
      "code_information": [
        {
          "code": "3600487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X140MM P99-100-2814",
      "code_information": [
        {
          "code": "3600522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-LK QR 10MMHEX P45-941-0002",
      "code_information": [
        {
          "code": "3600606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.4X95MM P45-960-2495",
      "code_information": [
        {
          "code": "3600612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM CN DSDS1040",
      "code_information": [
        {
          "code": "3600691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.9 CANN AR-8741-25",
      "code_information": [
        {
          "code": "3600716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUTERSINK-ISO MXM-074-ISO",
      "code_information": [
        {
          "code": "3600769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-18700-20",
      "code_information": [
        {
          "code": "3600864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB SMALL AR-18700-34",
      "code_information": [
        {
          "code": "3600865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM AR-8945-30C",
      "code_information": [
        {
          "code": "3600872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-8967-40C",
      "code_information": [
        {
          "code": "3600876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.5MM 56014500",
      "code_information": [
        {
          "code": "3600979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 2868-20-012",
      "code_information": [
        {
          "code": "3600982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X150 5028-8-150",
      "code_information": [
        {
          "code": "3600991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X300 5028-8-300",
      "code_information": [
        {
          "code": "3600992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 2868-20-014",
      "code_information": [
        {
          "code": "3601008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM LG AR-18800-16",
      "code_information": [
        {
          "code": "3601015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3601016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-18800-49",
      "code_information": [
        {
          "code": "3601017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-6.7MM CANN AR-8967-67C",
      "code_information": [
        {
          "code": "3601045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2MM AO AR-18700-88",
      "code_information": [
        {
          "code": "3601047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X16MM 03.617.916",
      "code_information": [
        {
          "code": "3601076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM PC2-110135",
      "code_information": [
        {
          "code": "3601082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 P20-910-4000",
      "code_information": [
        {
          "code": "3601103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2010",
      "code_information": [
        {
          "code": "3601105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.9X140 P99-110-2914",
      "code_information": [
        {
          "code": "3601117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-RM 2.5X1150MM 351.708S",
      "code_information": [
        {
          "code": "3601122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY EV10",
      "code_information": [
        {
          "code": "3601127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-12MM 86-0712",
      "code_information": [
        {
          "code": "3601252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-14MM 86-0714",
      "code_information": [
        {
          "code": "3601253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3601317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-2-0 ANCHOR W/CAN 4721",
      "code_information": [
        {
          "code": "3601325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLER BLACK 45 48345T",
      "code_information": [
        {
          "code": "3601353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI 1.1MM AR-18700-06",
      "code_information": [
        {
          "code": "3601374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL ENFIT",
      "code_information": [
        {
          "code": "3601439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X160MM P99-100-2816",
      "code_information": [
        {
          "code": "3601457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.6X160MM P99-100-3616",
      "code_information": [
        {
          "code": "3601458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-6.5-5.5X30 MOD 1119.1530",
      "code_information": [
        {
          "code": "3601579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-SHANNON 3MM P99-105-3080S",
      "code_information": [
        {
          "code": "3601619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2/SRT AR-18700-89",
      "code_information": [
        {
          "code": "3601712",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.7MM CSS-072-47-SQ",
      "code_information": [
        {
          "code": "3601732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.1X160MM P99-100-3116",
      "code_information": [
        {
          "code": "3601958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-EXTERNAL TRL 1601",
      "code_information": [
        {
          "code": "3601977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AO AR-18700-58",
      "code_information": [
        {
          "code": "3602020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HEX 2.5 MICA 57S02025",
      "code_information": [
        {
          "code": "3602089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER 60°CVD 1600574",
      "code_information": [
        {
          "code": "3602108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.X220MM AO 703901",
      "code_information": [
        {
          "code": "3602150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE 3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATION-BIASURGE BAS-0101",
      "code_information": [
        {
          "code": "3602440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM LONG AR-8970-30L",
      "code_information": [
        {
          "code": "3602582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP PEARL 5.7MM",
      "code_information": [
        {
          "code": "3602601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP CORAL 4.6MM",
      "code_information": [
        {
          "code": "3602602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CEMENT LL 2839-99-002",
      "code_information": [
        {
          "code": "3602865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DRILL W/NEEDLE 72205692",
      "code_information": [
        {
          "code": "3602934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-UNI PIN P45-970-2000",
      "code_information": [
        {
          "code": "3602946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BLUNT 4X45M P45-196-5045",
      "code_information": [
        {
          "code": "3602947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.4X160MM P45-960-3416",
      "code_information": [
        {
          "code": "3602948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-1H WO/ATTC P45-920-0001",
      "code_information": [
        {
          "code": "3603021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-5MM HLF PN P45-925-0105",
      "code_information": [
        {
          "code": "3603024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3603100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER DOME 7MM P20-070-WD00",
      "code_information": [
        {
          "code": "3603132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL LG 2.4X160M P99-100-2416",
      "code_information": [
        {
          "code": "3603134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 4.5MM AR-8945-45C",
      "code_information": [
        {
          "code": "3603164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3603223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL WIDENING 4MM 92141",
      "code_information": [
        {
          "code": "3603263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X82 P65-105-3030-S",
      "code_information": [
        {
          "code": "3603433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2X8X72 P65-105-2008-S",
      "code_information": [
        {
          "code": "3603436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-3.5X8MM BLUE 48230B",
      "code_information": [
        {
          "code": "3603757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2.5X8MM WHITE 48230W",
      "code_information": [
        {
          "code": "3603758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X8MM GRAY 48230M",
      "code_information": [
        {
          "code": "3603761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.7 FOOTPRINT 72205888",
      "code_information": [
        {
          "code": "3603793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-PLATE TEMP 705019",
      "code_information": [
        {
          "code": "3603817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-BL NEEDLE AR-7289",
      "code_information": [
        {
          "code": "3603840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-STERNAL AR-7288T",
      "code_information": [
        {
          "code": "3603885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP 388.174",
      "code_information": [
        {
          "code": "3603898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP DG 317.781",
      "code_information": [
        {
          "code": "3603899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW T20 57DRVT20",
      "code_information": [
        {
          "code": "3603903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INDUCTIVE HST NR340K9256",
      "code_information": [
        {
          "code": "3603913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUCKLE-INDUCTIVE NR340B9256",
      "code_information": [
        {
          "code": "3603930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QFIX 1.8MM 72290118",
      "code_information": [
        {
          "code": "3603977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FEN JT 2MM PIN MPDP0020",
      "code_information": [
        {
          "code": "3604047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.6 F/4MM MSN10012",
      "code_information": [
        {
          "code": "3604051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X100 P65-105-3031-S",
      "code_information": [
        {
          "code": "3604127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM AR-4160-24",
      "code_information": [
        {
          "code": "3604150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.3 F/4.5MM MSN10006",
      "code_information": [
        {
          "code": "3604155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STIM 8225401",
      "code_information": [
        {
          "code": "3604210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT TPT",
      "code_information": [
        {
          "code": "3604211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X200X100 P65-105-3020-S",
      "code_information": [
        {
          "code": "3604269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK RC AR-3650DS",
      "code_information": [
        {
          "code": "3604296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HD SCORPION AR-13999HDN",
      "code_information": [
        {
          "code": "3604298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLV 1.8X400 643518400",
      "code_information": [
        {
          "code": "3604331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-SMTH 1.8X400 641018400",
      "code_information": [
        {
          "code": "3604332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TRC 3X370 AR-9091K-30",
      "code_information": [
        {
          "code": "3604350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 1.7X120 P99-110-1712",
      "code_information": [
        {
          "code": "3604378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-RELINE C 3990002",
      "code_information": [
        {
          "code": "3604439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO 2.2F/115 CYB-2",
      "code_information": [
        {
          "code": "3604566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 3MM 5820-009-030",
      "code_information": [
        {
          "code": "3604572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 4MM 5820-009-040",
      "code_information": [
        {
          "code": "3604573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MARK OMNI H787137097015",
      "code_information": [
        {
          "code": "3604575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE 28164MC-S",
      "code_information": [
        {
          "code": "3604595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UTERINE 30 KC-RUMI-30",
      "code_information": [
        {
          "code": "3604602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-25",
      "code_information": [
        {
          "code": "3604603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-40",
      "code_information": [
        {
          "code": "3604604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE 48345W",
      "code_information": [
        {
          "code": "3604672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 BLUE 48345B",
      "code_information": [
        {
          "code": "3604673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 100 AR-8964R-150",
      "code_information": [
        {
          "code": "3604778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 250 AR-8964R-250",
      "code_information": [
        {
          "code": "3604779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 300 AR-8964R-300",
      "code_information": [
        {
          "code": "3604780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.5X135MM 542020",
      "code_information": [
        {
          "code": "3604831",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO HF 125 AR-3210-0052",
      "code_information": [
        {
          "code": "3604836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BN 3X900 AR-9095-39S",
      "code_information": [
        {
          "code": "3604848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM CN AR-1218-50",
      "code_information": [
        {
          "code": "3604938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED PRASS 8227304",
      "code_information": [
        {
          "code": "3604956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X145MM 542050",
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        {
          "code": "3604974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER TUBE 22FR 98433",
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        {
          "code": "3604979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-3H RANCHO 76-10208",
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        {
          "code": "3605033",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3MM P20-915-3000",
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        {
          "code": "3605072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "TROCAR-3.5/SHORT AR-8964-15",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-17\\\"\\\" AR-7237-17LN",
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        {
          "code": "3605098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSSEPTAL FND01902",
      "code_information": [
        {
          "code": "3824363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X14X5MM 607414",
      "code_information": [
        {
          "code": "3900003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X16X6MM 607416",
      "code_information": [
        {
          "code": "3900004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X18X7MM 607418",
      "code_information": [
        {
          "code": "3900005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X20X8MM 607420",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X22X9MM 607422",
      "code_information": [
        {
          "code": "3900007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X24X10MM 607424",
      "code_information": [
        {
          "code": "3900008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X26X12MM 607426",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X28X14MM 607428",
      "code_information": [
        {
          "code": "3900010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X30X14MM 607430",
      "code_information": [
        {
          "code": "3900011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X32X14MM 607432",
      "code_information": [
        {
          "code": "3900012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X34X14MM 607434",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X38X14MM 607438",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X40X14MM 607440",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X42X14MM 607442",
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          "code": "3900016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X44X15MM 607444",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 4.0X46X15MM 607446",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 4.0X48X15MM 607448",
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        },
        {
          "code": "0270",
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        }
      ],
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 4.0X50X15MM 607450",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANC 4.0X55X16MM 607455",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X60X16MM 607460",
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        {
          "code": "3900022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X16MM 607316",
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        {
          "code": "3900023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X18MM 607318",
      "code_information": [
        {
          "code": "3900024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X20MM 607320",
      "code_information": [
        {
          "code": "3900025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X26MM 607326",
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        {
          "code": "3900026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X28MM 607328",
      "code_information": [
        {
          "code": "3900027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X30MM 607330",
      "code_information": [
        {
          "code": "3900028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X32MM 607332",
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        {
          "code": "3900029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X34MM 607334",
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        {
          "code": "3900030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 4.0X36MM 607336",
      "code_information": [
        {
          "code": "3900031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 4X120/35TH 5027-4-120",
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        {
          "code": "3900101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X48MM 661148",
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        {
          "code": "3900219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X65MM 601665",
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        {
          "code": "3900228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X12MM 662512",
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        {
          "code": "3900229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X13MM 662513",
      "code_information": [
        {
          "code": "3900230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X14MM 662514",
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        {
          "code": "3900231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X15MM 662515",
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        {
          "code": "3900232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X16MM 662516",
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        {
          "code": "3900233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X18MM 662518",
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        {
          "code": "3900234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X20MM 662520",
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        {
          "code": "3900235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X22MM 662522",
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        {
          "code": "3900236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X24MM 662524",
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        {
          "code": "3900237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X5MM 662505",
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        {
          "code": "3900238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X10MM 661310",
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        {
          "code": "3900249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X12MM 661312",
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          "code": "3900250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X14MM 661314",
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          "code": "3900251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X16MM 661316",
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        {
          "code": "3900252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X18MM 661318",
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        {
          "code": "3900253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X20MM 661320",
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        {
          "code": "3900254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK PERI 5X8MM 661308",
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        {
          "code": "3900255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.0X122MM AO 705137",
      "code_information": [
        {
          "code": "3900256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X18MM 656618",
      "code_information": [
        {
          "code": "3900257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X20MM 656620",
      "code_information": [
        {
          "code": "3900258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X22MM 656622",
      "code_information": [
        {
          "code": "3900259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X24MM 656624",
      "code_information": [
        {
          "code": "3900260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X26MM 656626",
      "code_information": [
        {
          "code": "3900261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X16MM 656616",
      "code_information": [
        {
          "code": "3900262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X38MM 656338",
      "code_information": [
        {
          "code": "3900273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X40MM 656340",
      "code_information": [
        {
          "code": "3900274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X45MM 656345",
      "code_information": [
        {
          "code": "3900275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X50MM 656350",
      "code_information": [
        {
          "code": "3900276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-WIRE K 1.6X200MM 705136",
      "code_information": [
        {
          "code": "3900277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X105MM 602905",
      "code_information": [
        {
          "code": "3900278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X110MM 602910",
      "code_information": [
        {
          "code": "3900279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X40MM 602640",
      "code_information": [
        {
          "code": "3900280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X45MM 602645",
      "code_information": [
        {
          "code": "3900281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X50MM 602650",
      "code_information": [
        {
          "code": "3900282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X55MM 602655",
      "code_information": [
        {
          "code": "3900283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X60MM 602860",
      "code_information": [
        {
          "code": "3900284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X65MM 602665",
      "code_information": [
        {
          "code": "3900285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X12MM 657612",
      "code_information": [
        {
          "code": "3900294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X13MM 657613",
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        {
          "code": "3900295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X15MM 657615",
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        {
          "code": "3900297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X16MM 657616",
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        {
          "code": "3900298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X18MM 657618",
      "code_information": [
        {
          "code": "3900299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X22MM 657622",
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        {
          "code": "3900300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X28MM 657628",
      "code_information": [
        {
          "code": "3900303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/1.7MM 57-10391",
      "code_information": [
        {
          "code": "3900462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/2.3 57-15391",
      "code_information": [
        {
          "code": "3900463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7MM 57-10392",
      "code_information": [
        {
          "code": "3900464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7MM 57-10395",
      "code_information": [
        {
          "code": "3900465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/2.3 57-15392",
      "code_information": [
        {
          "code": "3900466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/2.3MM 57-15395",
      "code_information": [
        {
          "code": "3900467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/1.7MM 57-10380",
      "code_information": [
        {
          "code": "3900468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3/LT 57-15324",
      "code_information": [
        {
          "code": "3900469",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 10H/1.7 57-10310",
      "code_information": [
        {
          "code": "3900470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 7H/1.7MM 57-10360",
      "code_information": [
        {
          "code": "3900471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/1.7MM 57-10368",
      "code_information": [
        {
          "code": "3900472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/2.3MM 57-15361",
      "code_information": [
        {
          "code": "3900473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 20H/2X111MM 629640",
      "code_information": [
        {
          "code": "3900485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.0X67MM 629650",
      "code_information": [
        {
          "code": "3900486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2X28MM 629644",
      "code_information": [
        {
          "code": "3900487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2X41MM 629646",
      "code_information": [
        {
          "code": "3900488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.0X54MM 629648",
      "code_information": [
        {
          "code": "3900489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X10H/2.0X62MM 629771",
      "code_information": [
        {
          "code": "3900490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X5H/2X34MM 629770",
      "code_information": [
        {
          "code": "3900491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X10H/2.0X62MM 629773",
      "code_information": [
        {
          "code": "3900492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X5H/2.0X34MM 629772",
      "code_information": [
        {
          "code": "3900493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 5X10H/2.0X62MM 629775",
      "code_information": [
        {
          "code": "3900494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-PIN LENGTHEN 4960-3-020",
      "code_information": [
        {
          "code": "3900495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LENGTHENER 4960-3-010",
      "code_information": [
        {
          "code": "3900496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-RADIAL LONG 54-25401",
      "code_information": [
        {
          "code": "3900497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-RADIAL SHORT 54-25400",
      "code_information": [
        {
          "code": "3900498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 20H/2.4X135 629700",
      "code_information": [
        {
          "code": "3900513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2.4X35 629704",
      "code_information": [
        {
          "code": "3900514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2.4X50MM 629706",
      "code_information": [
        {
          "code": "3900515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.4X65MM 629708",
      "code_information": [
        {
          "code": "3900516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X10H/2.4X76MM 629777",
      "code_information": [
        {
          "code": "3900517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
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          ]
        }
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      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
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        {
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          "type": "RC"
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        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 5X10H/2.4X76MM 629781",
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          "code": "3900519",
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.7X79MM 629730",
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        {
          "code": "0270",
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        {
          "setting": "outpatient",
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "0270",
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        {
          "setting": "outpatient",
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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            }
          ]
        }
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      "service_type": "CDM"
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    {
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        {
          "code": "0270",
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2.7X47MM 629726",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.7X64MM 629728",
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        {
          "code": "0270",
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      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 20H/2.7X34 629770",
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        {
          "code": "0270",
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "0270",
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              "payer_name": "Anthem",
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          ]
        }
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      "service_type": "CDM"
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    {
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        },
        {
          "code": "0270",
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 2X5H/2.7X47MM 629782",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1054.8952,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 5H/98/RT 628225",
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        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
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    },
    {
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        {
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      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
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    },
    {
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "OVERTUBE- ESOPHAGEAL 00711146",
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        {
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        }
      ],
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD INJECTOR",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHINCTEROTOME-AUTOTOME RX",
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        {
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      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
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        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-STONE 1.9FR     390-105",
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        {
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        }
      ],
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
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        }
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLUTED 4.0MM  315.40",
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TIB DRILL 195MM     315.29",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 PERIPH SCREW",
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        {
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        }
      ],
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5",
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        },
        {
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          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X230   1806-35xxS",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 535.3604,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        72-2011",
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        {
          "code": "3002384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 324.214",
      "code_information": [
        {
          "code": "3002392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM 702453",
      "code_information": [
        {
          "code": "3002396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8737-09",
      "code_information": [
        {
          "code": "3002398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 255589000",
      "code_information": [
        {
          "code": "3002401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.0 SCREW DRIVER",
      "code_information": [
        {
          "code": "3002656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1xMM 2868-20-01x",
      "code_information": [
        {
          "code": "3002771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SIZES     703xxx",
      "code_information": [
        {
          "code": "3002789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SZ   2883-01-xxx",
      "code_information": [
        {
          "code": "3012205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0          323.062",
      "code_information": [
        {
          "code": "3012319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          80-0387",
      "code_information": [
        {
          "code": "3012332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.103",
      "code_information": [
        {
          "code": "3012342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CTR INDIANA TOME  200060",
      "code_information": [
        {
          "code": "3021156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE RGLR",
      "code_information": [
        {
          "code": "3029340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE XL",
      "code_information": [
        {
          "code": "3029342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-SCREW GUIDE      230790004",
      "code_information": [
        {
          "code": "3030620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PNEUMATIC ALL SZ  840-7s",
      "code_information": [
        {
          "code": "3034527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PRASS FLUSH TIP  8225101",
      "code_information": [
        {
          "code": "3034535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-ANASTOCLIP 4001-00",
      "code_information": [
        {
          "code": "3039801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GRAY     ECR45M",
      "code_information": [
        {
          "code": "3039879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.0 CANN DRI",
      "code_information": [
        {
          "code": "3040703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 3.0MM",
      "code_information": [
        {
          "code": "3058676",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6MM AR 8943-02",
      "code_information": [
        {
          "code": "3058783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL CONICAL 3+4MM",
      "code_information": [
        {
          "code": "3058870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM xxMM JLATC",
      "code_information": [
        {
          "code": "3059041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-HCS xxMM",
      "code_information": [
        {
          "code": "3059042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM XFO130022",
      "code_information": [
        {
          "code": "3059096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 15CMX2.2MM 15MH22",
      "code_information": [
        {
          "code": "3059107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X216MM SHORT",
      "code_information": [
        {
          "code": "3059144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE GST45W",
      "code_information": [
        {
          "code": "3059268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL MN60MA 00.0",
      "code_information": [
        {
          "code": "3060419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAGITTAL STD 116170",
      "code_information": [
        {
          "code": "3060497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 8",
      "code_information": [
        {
          "code": "3084826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL LONG 5MM      B5XT",
      "code_information": [
        {
          "code": "3085206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 7.5FR MEGA IAB",
      "code_information": [
        {
          "code": "3085536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 BLUE XI",
      "code_information": [
        {
          "code": "3186035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 GREEN XI",
      "code_information": [
        {
          "code": "3186037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRST 45 WHTE 48645W",
      "code_information": [
        {
          "code": "3186041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-EPISTAT XOMED    15-27031",
      "code_information": [
        {
          "code": "3507977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HELMET-PROTECTIVE SOFT A8000",
      "code_information": [
        {
          "code": "3519273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 102MM X 11GA",
      "code_information": [
        {
          "code": "3526202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO MEASURING 2.0X110MM",
      "code_information": [
        {
          "code": "3526234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO LONG 2.4X140MM",
      "code_information": [
        {
          "code": "3526301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-COMPLEX BREAST DYNJ60133",
      "code_information": [
        {
          "code": "3526421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-PURGE 043-0003",
      "code_information": [
        {
          "code": "3526914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER TORX 703667",
      "code_information": [
        {
          "code": "3527081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST PLEUREVAC A-9250LF",
      "code_information": [
        {
          "code": "3527083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-MICROBLATOR 30 AC4050-01",
      "code_information": [
        {
          "code": "3527275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM WHITE 47630W",
      "code_information": [
        {
          "code": "3527881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM BLUE 48630B",
      "code_information": [
        {
          "code": "3527882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION",
      "code_information": [
        {
          "code": "3549013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.0X135MM 703690",
      "code_information": [
        {
          "code": "3549128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 2.7X122MM 703695",
      "code_information": [
        {
          "code": "3549129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703880",
      "code_information": [
        {
          "code": "3549137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TORFLEX GUIDING",
      "code_information": [
        {
          "code": "3549175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL 10ML TWIN PK",
      "code_information": [
        {
          "code": "3549261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM CANN AR-1218-40",
      "code_information": [
        {
          "code": "3549308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 3.2 X 216 705",
      "code_information": [
        {
          "code": "3549843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PILOTED 6.0MM AR-1450",
      "code_information": [
        {
          "code": "3550002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR ACCESS 21030",
      "code_information": [
        {
          "code": "3550197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563010",
      "code_information": [
        {
          "code": "3550451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563020",
      "code_information": [
        {
          "code": "3550452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563030",
      "code_information": [
        {
          "code": "3550453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563040",
      "code_information": [
        {
          "code": "3550454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERC INSERT AR-1923PK",
      "code_information": [
        {
          "code": "3550583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP 3 BAG SPIKE BLOOD IV",
      "code_information": [
        {
          "code": "3550718",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-910-3500",
      "code_information": [
        {
          "code": "3550772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.3X100MM P99-100-1310",
      "code_information": [
        {
          "code": "3559004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X12MM VASC SIG30TAV",
      "code_information": [
        {
          "code": "3559124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 16FR 98437",
      "code_information": [
        {
          "code": "3559429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LARYNGOSCOPE-CMOS IDEO RHINO",
      "code_information": [
        {
          "code": "3559674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-NAVIGATION TDNC001",
      "code_information": [
        {
          "code": "3559689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE DBL ABS-10010S",
      "code_information": [
        {
          "code": "3598066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACP+ACD-A ABS-10011T",
      "code_information": [
        {
          "code": "3598067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI FT CMP AR-8737-41",
      "code_information": [
        {
          "code": "3598177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X60MM 58850025",
      "code_information": [
        {
          "code": "3598253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X14MM 03.617.914",
      "code_information": [
        {
          "code": "3598581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T25 PERIP 5901-1128",
      "code_information": [
        {
          "code": "3599025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 32FR 5532S",
      "code_information": [
        {
          "code": "3599075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 40FR 5540B",
      "code_information": [
        {
          "code": "3599076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8X200MM 03.133.108",
      "code_information": [
        {
          "code": "3599159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/110X30MM 03.133.100",
      "code_information": [
        {
          "code": "3599236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/140X60MM 03.133.101",
      "code_information": [
        {
          "code": "3599240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/170X80 03.133.107",
      "code_information": [
        {
          "code": "3599241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 4.2X120 P99-100-421",
      "code_information": [
        {
          "code": "3599394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X130 1806-3550S",
      "code_information": [
        {
          "code": "3599470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STERILE PERC 150MM 9733236",
      "code_information": [
        {
          "code": "3599775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 2MM MR8-15MH22",
      "code_information": [
        {
          "code": "3599776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 545CC SSZ-X545",
      "code_information": [
        {
          "code": "3599822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 485CC SSZ-F485",
      "code_information": [
        {
          "code": "3599823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 365CC SSZ-F365",
      "code_information": [
        {
          "code": "3599824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT DPT5",
      "code_information": [
        {
          "code": "3599926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM AR-18800-19",
      "code_information": [
        {
          "code": "3600284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-NANO 125MM AR-3210-0053",
      "code_information": [
        {
          "code": "3600399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3600410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM SHRT AR-18800-18",
      "code_information": [
        {
          "code": "3600411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CN 2MM AR-8610DB-30C",
      "code_information": [
        {
          "code": "3600487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X140MM P99-100-2814",
      "code_information": [
        {
          "code": "3600522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.4X95MM P45-960-2495",
      "code_information": [
        {
          "code": "3600612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-18700-20",
      "code_information": [
        {
          "code": "3600864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM AR-8945-30C",
      "code_information": [
        {
          "code": "3600872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-8967-40C",
      "code_information": [
        {
          "code": "3600876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.5MM 56014500",
      "code_information": [
        {
          "code": "3600979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 2868-20-012",
      "code_information": [
        {
          "code": "3600982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X150 5028-8-150",
      "code_information": [
        {
          "code": "3600991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X300 5028-8-300",
      "code_information": [
        {
          "code": "3600992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM LG AR-18800-16",
      "code_information": [
        {
          "code": "3601015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3601016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.9X140 P99-110-2914",
      "code_information": [
        {
          "code": "3601117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-12MM 86-0712",
      "code_information": [
        {
          "code": "3601252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLER BLACK 45 48345T",
      "code_information": [
        {
          "code": "3601353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL ENFIT",
      "code_information": [
        {
          "code": "3601439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X160MM P99-100-2816",
      "code_information": [
        {
          "code": "3601457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.6X160MM P99-100-3616",
      "code_information": [
        {
          "code": "3601458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2/SRT AR-18700-89",
      "code_information": [
        {
          "code": "3601712",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.7MM CSS-072-47-SQ",
      "code_information": [
        {
          "code": "3601732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.1X160MM P99-100-3116",
      "code_information": [
        {
          "code": "3601958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP PEARL 5.7MM",
      "code_information": [
        {
          "code": "3602601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DRILL W/NEEDLE 72205692",
      "code_information": [
        {
          "code": "3602934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-UNI PIN P45-970-2000",
      "code_information": [
        {
          "code": "3602946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BLUNT 4X45M P45-196-5045",
      "code_information": [
        {
          "code": "3602947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.4X160MM P45-960-3416",
      "code_information": [
        {
          "code": "3602948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-5MM HLF PN P45-925-0105",
      "code_information": [
        {
          "code": "3603024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3603100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER DOME 7MM P20-070-WD00",
      "code_information": [
        {
          "code": "3603132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL LG 2.4X160M P99-100-2416",
      "code_information": [
        {
          "code": "3603134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2X8X72 P65-105-2008-S",
      "code_information": [
        {
          "code": "3603436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-3.5X8MM BLUE 48230B",
      "code_information": [
        {
          "code": "3603757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.7 FOOTPRINT 72205888",
      "code_information": [
        {
          "code": "3603793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-PLATE TEMP 705019",
      "code_information": [
        {
          "code": "3603817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP 388.174",
      "code_information": [
        {
          "code": "3603898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW T20 57DRVT20",
      "code_information": [
        {
          "code": "3603903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.6 F/4MM MSN10012",
      "code_information": [
        {
          "code": "3604051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM AR-4160-24",
      "code_information": [
        {
          "code": "3604150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STIM 8225401",
      "code_information": [
        {
          "code": "3604210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLV 1.8X400 643518400",
      "code_information": [
        {
          "code": "3604331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-SMTH 1.8X400 641018400",
      "code_information": [
        {
          "code": "3604332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 1.7X120 P99-110-1712",
      "code_information": [
        {
          "code": "3604378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO 2.2F/115 CYB-2",
      "code_information": [
        {
          "code": "3604566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 3MM 5820-009-030",
      "code_information": [
        {
          "code": "3604572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UTERINE 30 KC-RUMI-30",
      "code_information": [
        {
          "code": "3604602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-25",
      "code_information": [
        {
          "code": "3604603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONTROLLER-AZUR DETACH 45-4001",
      "code_information": [
        {
          "code": "1411129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 3FR 0   390-103",
      "code_information": [
        {
          "code": "3002153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3889.9195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-1.3F NITINOL STONE",
      "code_information": [
        {
          "code": "3002170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 2.0",
      "code_information": [
        {
          "code": "3002254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1209.5175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0          357.407",
      "code_information": [
        {
          "code": "3002356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1989.7258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              316.286",
      "code_information": [
        {
          "code": "3002781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1655.5097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT ALL    18-84004HR",
      "code_information": [
        {
          "code": "3003228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2744.9096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACCESS 10 GAUGE",
      "code_information": [
        {
          "code": "3012102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1155.0197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SKYLINE 14MM   286820014",
      "code_information": [
        {
          "code": "3012132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING 3.5FR  370-115",
      "code_information": [
        {
          "code": "3013315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1142.7855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-EXTRA STRENGTH GRASPING",
      "code_information": [
        {
          "code": "3013324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2243.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERTER-SCREW T8   03.617.904",
      "code_information": [
        {
          "code": "3019821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1139.4489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE   28164Mx/3",
      "code_information": [
        {
          "code": "3019825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2981.2521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACIUM 30 CM TUNNELING TOOL",
      "code_information": [
        {
          "code": "3019908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1366.3377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KOH ALL",
      "code_information": [
        {
          "code": "3022136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1434.1819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STR COLD KNIFE K-SB",
      "code_information": [
        {
          "code": "3022228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM EYE WENTWORTH",
      "code_information": [
        {
          "code": "3029171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1392.4744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "QFIX-DISP SHOULDER 2.8MM",
      "code_information": [
        {
          "code": "3029223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1455.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STRT 302-431-000",
      "code_information": [
        {
          "code": "3034513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5897.4405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE0-FIAPC CIRCUMFRENTIAL",
      "code_information": [
        {
          "code": "3034521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1284.0349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60W       GST60W",
      "code_information": [
        {
          "code": "3039929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1146.1221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3040420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1692.2123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SM JOINT 2.4MM DRILL&GUID",
      "code_information": [
        {
          "code": "3058763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL WIDENING xMM",
      "code_information": [
        {
          "code": "3058871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7124.7532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR 200-120",
      "code_information": [
        {
          "code": "3059077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X216MM SHORT",
      "code_information": [
        {
          "code": "3059146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4823.6114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST45B",
      "code_information": [
        {
          "code": "3059269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45GREEN GST45G",
      "code_information": [
        {
          "code": "3059276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8426.0272,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAG NARROW 116171",
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        {
          "code": "3060498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PUSHLOCK 2.9  AR-1923DS",
      "code_information": [
        {
          "code": "3083078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3731.9871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI SLEEVE 32F 5232B",
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        {
          "code": "3083150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1926.3304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PROGEL EXTENDED PGEN005-06",
      "code_information": [
        {
          "code": "3083771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 14081.5642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM         14MH30",
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        {
          "code": "3084589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT INSTRUM 9733533XOM",
      "code_information": [
        {
          "code": "3084911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT PATIENT",
      "code_information": [
        {
          "code": "3084948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2211.6097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6 703702",
      "code_information": [
        {
          "code": "3087918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7526.2574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM 8MM JLATCH",
      "code_information": [
        {
          "code": "3526157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 152MM X 11GA",
      "code_information": [
        {
          "code": "3526203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW CANN HEX 2.5MM",
      "code_information": [
        {
          "code": "3526498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2073.1408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ASSIST CUSTOM BB10M33R",
      "code_information": [
        {
          "code": "3526535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4134.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION KNEE AR-12990",
      "code_information": [
        {
          "code": "3526976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EUS 19GA",
      "code_information": [
        {
          "code": "3526981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9711.7304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN DRILL 3.0X170MM 70535",
      "code_information": [
        {
          "code": "3526990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7167.5729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.4X150MM 702448",
      "code_information": [
        {
          "code": "3527149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6548.0775,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLACK GST45T",
      "code_information": [
        {
          "code": "3548010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION 14FR",
      "code_information": [
        {
          "code": "3549014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 0210",
      "code_information": [
        {
          "code": "3549040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON 50 PASSPORT",
      "code_information": [
        {
          "code": "3549108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP-50",
      "code_information": [
        {
          "code": "3549153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANN 3.0MM",
      "code_information": [
        {
          "code": "3549162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9536.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL HEARTSPAN",
      "code_information": [
        {
          "code": "3549177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP",
      "code_information": [
        {
          "code": "3549202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1486.4553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-BLADE 45-35015",
      "code_information": [
        {
          "code": "3549235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2951.2227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 703896",
      "code_information": [
        {
          "code": "3549240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4966.5291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X230MM 700355",
      "code_information": [
        {
          "code": "3549276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 10602.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACC-SELECTRA IC 50 392290",
      "code_information": [
        {
          "code": "3549414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5416.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X122MM 703897",
      "code_information": [
        {
          "code": "3549436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8520.0081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL J-HATCH 14MM",
      "code_information": [
        {
          "code": "3549445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 3.0MM",
      "code_information": [
        {
          "code": "3549453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SHAFT CANN 6192.0040",
      "code_information": [
        {
          "code": "3549723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3174.7749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 3.5X122MM 703694",
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        {
          "code": "3549799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3549806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 4.3X216 705043",
      "code_information": [
        {
          "code": "3549844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAGNET-REPLACEMENT COCHLEAR",
      "code_information": [
        {
          "code": "3549900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.4X122MM 703696",
      "code_information": [
        {
          "code": "3549904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145 03.010.104",
      "code_information": [
        {
          "code": "3550057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-TENSIONER AR-5815",
      "code_information": [
        {
          "code": "3550191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5420.8628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GJ 22 FR FEEDING 8660-22",
      "code_information": [
        {
          "code": "3550289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASCOPE-RHINOLARYNGO SLIM 51000",
      "code_information": [
        {
          "code": "3550507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STIM 2862-02-203",
      "code_information": [
        {
          "code": "3550853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 11041.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4X195MM ST 315.40S",
      "code_information": [
        {
          "code": "3550855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 29277.5528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-INFUSION 8FR BIOFLO H787C",
      "code_information": [
        {
          "code": "3550906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1978.0477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STERNAL 99-006-01-04",
      "code_information": [
        {
          "code": "3559018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3981.676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 2.3X120MM",
      "code_information": [
        {
          "code": "3559139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15X45 XT SIG45AXT",
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        {
          "code": "3559637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4925.9338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL VERACROSS",
      "code_information": [
        {
          "code": "3559675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1586.5533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM AR-8737-34",
      "code_information": [
        {
          "code": "3598007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9912.4825,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PASS STIM DM-8225101",
      "code_information": [
        {
          "code": "3598049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7374.4421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-14CC MIX ABS-2000",
      "code_information": [
        {
          "code": "3598068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5F 007250P",
      "code_information": [
        {
          "code": "3598088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y-SHAPE SHUNT FV015T",
      "code_information": [
        {
          "code": "3598131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1255.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HOOK/TRI BLADE 2056-6",
      "code_information": [
        {
          "code": "3598195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-915-3500",
      "code_information": [
        {
          "code": "3598232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2358.9762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5.5X60MM 58850055",
      "code_information": [
        {
          "code": "3598254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1246.7762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SCALED 2X150MM 705134",
      "code_information": [
        {
          "code": "3598286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T TRACH SZ10 LT-510-S",
      "code_information": [
        {
          "code": "3598307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3857.6657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-MINIONE M1-1-1824",
      "code_information": [
        {
          "code": "3598321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45",
      "code_information": [
        {
          "code": "3598675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM AR-8737-58",
      "code_information": [
        {
          "code": "3598691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT4.0 CA DRILL AR-8956C-40PD",
      "code_information": [
        {
          "code": "3598808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X60MM 58850028",
      "code_information": [
        {
          "code": "3599257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-CANN 4MM 705260",
      "code_information": [
        {
          "code": "3599495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3409.4491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.012",
      "code_information": [
        {
          "code": "3599540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1688.3196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TALAR PEG 4MM IB200020",
      "code_information": [
        {
          "code": "3599675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM MR8-14MH30",
      "code_information": [
        {
          "code": "3599777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3775.3629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 400CC SSZ-X400",
      "code_information": [
        {
          "code": "3599825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3X100 MWM100",
      "code_information": [
        {
          "code": "3600385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 10446.8946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 3.5X160 P99-110-3516",
      "code_information": [
        {
          "code": "3600392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2640.9189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM CN DSDS1040",
      "code_information": [
        {
          "code": "3600691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB SMALL AR-18700-34",
      "code_information": [
        {
          "code": "3600865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2515.2403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-6.7MM CANN AR-8967-67C",
      "code_information": [
        {
          "code": "3601045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2926.7543,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X16MM 03.617.916",
      "code_information": [
        {
          "code": "3601076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2775.4951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM PC2-110135",
      "code_information": [
        {
          "code": "3601082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1960.8086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 P20-910-4000",
      "code_information": [
        {
          "code": "3601103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY EV10",
      "code_information": [
        {
          "code": "3601127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-14MM 86-0714",
      "code_information": [
        {
          "code": "3601253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3601317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8783.5995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-2-0 ANCHOR W/CAN 4721",
      "code_information": [
        {
          "code": "3601325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2762.1487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-6.5-5.5X30 MOD 1119.1530",
      "code_information": [
        {
          "code": "3601579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-SHANNON 3MM P99-105-3080S",
      "code_information": [
        {
          "code": "3601619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3561.2644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AO AR-18700-58",
      "code_information": [
        {
          "code": "3602020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6837.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HEX 2.5 MICA 57S02025",
      "code_information": [
        {
          "code": "3602089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.X220MM AO 703901",
      "code_information": [
        {
          "code": "3602150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE 3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3788.7093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATION-BIASURGE BAS-0101",
      "code_information": [
        {
          "code": "3602440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1735.5881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP CORAL 4.6MM",
      "code_information": [
        {
          "code": "3602602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CEMENT LL 2839-99-002",
      "code_information": [
        {
          "code": "3602865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL WIDENING 4MM 92141",
      "code_information": [
        {
          "code": "3603263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3611.8695,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X82 P65-105-3030-S",
      "code_information": [
        {
          "code": "3603433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4037.286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2.5X8MM WHITE 48230W",
      "code_information": [
        {
          "code": "3603758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X8MM GRAY 48230M",
      "code_information": [
        {
          "code": "3603761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 34308.5895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-BL NEEDLE AR-7289",
      "code_information": [
        {
          "code": "3603840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-STERNAL AR-7288T",
      "code_information": [
        {
          "code": "3603885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP DG 317.781",
      "code_information": [
        {
          "code": "3603899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1869.6082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QFIX 1.8MM 72290118",
      "code_information": [
        {
          "code": "3603977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FEN JT 2MM PIN MPDP0020",
      "code_information": [
        {
          "code": "3604047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X100 P65-105-3031-S",
      "code_information": [
        {
          "code": "3604127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT TPT",
      "code_information": [
        {
          "code": "3604211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1944.1256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X200X100 P65-105-3020-S",
      "code_information": [
        {
          "code": "3604269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HD SCORPION AR-13999HDN",
      "code_information": [
        {
          "code": "3604298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1843.4715,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TRC 3X370 AR-9091K-30",
      "code_information": [
        {
          "code": "3604350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1586.5533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-RELINE C 3990002",
      "code_information": [
        {
          "code": "3604439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2243.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 4MM 5820-009-040",
      "code_information": [
        {
          "code": "3604573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE 28164MC-S",
      "code_information": [
        {
          "code": "3604595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1248.4445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-40",
      "code_information": [
        {
          "code": "3604604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FUNNEL-KELLER 2 HA-005",
      "code_information": [
        {
          "code": "3000004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 498.2656,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM     03.617.9xx",
      "code_information": [
        {
          "code": "3002371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT 2.9MM    18-82904",
      "code_information": [
        {
          "code": "3003237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 127.3469,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER     62-27015",
      "code_information": [
        {
          "code": "3003253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 347.0064,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO              CYB-x",
      "code_information": [
        {
          "code": "3003505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 72.293,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION xMM 5820-009-0xx",
      "code_information": [
        {
          "code": "3003845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 175.1715,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 29FR 96370-029",
      "code_information": [
        {
          "code": "3004237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 10M OMS-T10BT",
      "code_information": [
        {
          "code": "3005080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-OMEGA        1004930",
      "code_information": [
        {
          "code": "3009748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ENDO LINEAR       ATS45",
      "code_information": [
        {
          "code": "3009970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 238.0108,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-PERCUTANEOUS DRILL 324.213",
      "code_information": [
        {
          "code": "3012223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.50x",
      "code_information": [
        {
          "code": "3012358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 427.6409,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T7 TORX 703665",
      "code_information": [
        {
          "code": "3012408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 134.0201,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 4CHAN 8227411",
      "code_information": [
        {
          "code": "3012587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 305.2989,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-ROLLER 24FR WA22038C",
      "code_information": [
        {
          "code": "3012594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 206.8692,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE BLUNT 2867-05-220",
      "code_information": [
        {
          "code": "3016132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 173.5032,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONETTED       3101055",
      "code_information": [
        {
          "code": "3021160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 146.2543,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MULTIFIRE SCORPION",
      "code_information": [
        {
          "code": "3027390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 243.0157,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 11M VS101011P",
      "code_information": [
        {
          "code": "3027592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 333.66,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CARTER/MOORE      7959E",
      "code_information": [
        {
          "code": "3029197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 56.7222,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASOPORE  5400-020-008",
      "code_information": [
        {
          "code": "3029293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 353.6796,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICLE SCREW    9450019",
      "code_information": [
        {
          "code": "3034581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 112.3322,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60T GST60T",
      "code_information": [
        {
          "code": "3039946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 258.5865,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-SHORT BEVEL 35",
      "code_information": [
        {
          "code": "3058621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 245.7962,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED",
      "code_information": [
        {
          "code": "3058948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 130.6835,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 4.3MM",
      "code_information": [
        {
          "code": "3059085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 166.2739,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTASIS RESOLUTION 36",
      "code_information": [
        {
          "code": "3059208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 42.8197,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60BLUE GST60B",
      "code_information": [
        {
          "code": "3059280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 155.1519,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE DISP FIRSTPASS",
      "code_information": [
        {
          "code": "3060480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5",
      "code_information": [
        {
          "code": "3069109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 488.8119,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER MOD.TRINKLE",
      "code_information": [
        {
          "code": "3079260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 245.7962,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3081128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 330.3234,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE WHITE VASECR35",
      "code_information": [
        {
          "code": "3081553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 439.8751,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-MIDAS LEGEND ALL 14BAxxDC",
      "code_information": [
        {
          "code": "3084380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 291.9525,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12MM         B12LT",
      "code_information": [
        {
          "code": "3085209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 239.123,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DISP INSTRUMENT MINI S-TAK",
      "code_information": [
        {
          "code": "3085539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 124.0103,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-EXCEL LONG 12MM   B12XT",
      "code_information": [
        {
          "code": "3085625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 149.0348,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON         1806-0073S",
      "code_information": [
        {
          "code": "3085870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 176.8398,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST60G",
      "code_information": [
        {
          "code": "3086960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 452.1093,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TWIST DRILL 2.3 72203160",
      "code_information": [
        {
          "code": "3087938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 451.5532,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRPAE 3-ARM S.I.E.  420290",
      "code_information": [
        {
          "code": "3139015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-SURGICAL POWDER",
      "code_information": [
        {
          "code": "3526249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 7.7854,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE A0 XTV008001",
      "code_information": [
        {
          "code": "3526333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 63.3954,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC XI DYNJ905698",
      "code_information": [
        {
          "code": "3526424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 426.5287,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-NEURO DYNJ60135",
      "code_information": [
        {
          "code": "3526427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 341.4454,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BARIATRIC DYNJ52366",
      "code_information": [
        {
          "code": "3526671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 61.7271,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3527286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 330.3234,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN 48630G",
      "code_information": [
        {
          "code": "3527883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-PLASMA STERILE   015",
      "code_information": [
        {
          "code": "3541330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 88.976,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTRODUCER LOCALIZATION",
      "code_information": [
        {
          "code": "3542520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 72.293,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANNULATED 5.0 705361",
      "code_information": [
        {
          "code": "3547933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6X135MM 703691",
      "code_information": [
        {
          "code": "3549125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ATSV II BE 8025H",
      "code_information": [
        {
          "code": "3549306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 298.6257,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PROFILE AR-1410LP",
      "code_information": [
        {
          "code": "3549310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 199.0838,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3549410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 311.9721,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-3.5 CAN DRILL AR-8956-35P",
      "code_information": [
        {
          "code": "3549430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 206.8692,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MINI SUTURE 72290128",
      "code_information": [
        {
          "code": "3549714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T8 TORX AO 703663",
      "code_information": [
        {
          "code": "3549847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 493.8168,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANNU STR",
      "code_information": [
        {
          "code": "3550047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 172.9471,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2009",
      "code_information": [
        {
          "code": "3550763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.6X130MM P99-110-2613",
      "code_information": [
        {
          "code": "3550773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO RESOLUTION 360",
      "code_information": [
        {
          "code": "3559020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 39.4831,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENFIT GJ FEEDING 18X45 825",
      "code_information": [
        {
          "code": "3559086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 126.7908,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-VAS",
      "code_information": [
        {
          "code": "3559125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN W/AO 2.7MM 705250",
      "code_information": [
        {
          "code": "3559186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 339.7771,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8737-35",
      "code_information": [
        {
          "code": "3598175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 182.4008,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE SG CTI-10155G",
      "code_information": [
        {
          "code": "3598399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 7.7854,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TI-KNOT 5MM 030404",
      "code_information": [
        {
          "code": "3598526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 285.2793,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X24MM 58850020",
      "code_information": [
        {
          "code": "3598638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 418.1872,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY",
      "code_information": [
        {
          "code": "3598673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 58.9466,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.6 CANN AR-8741-32",
      "code_information": [
        {
          "code": "3598694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 151.2592,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/170X80 03.133.103",
      "code_information": [
        {
          "code": "3599255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 181.2886,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVR 3.5X110 P99-110-3511",
      "code_information": [
        {
          "code": "3599772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 99.5419,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BONE BIOPSY CD1110",
      "code_information": [
        {
          "code": "3599838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-LK QR 10MMHEX P45-941-0002",
      "code_information": [
        {
          "code": "3600606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 149.5909,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.9 CANN AR-8741-25",
      "code_information": [
        {
          "code": "3600716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 219.1034,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUTERSINK-ISO MXM-074-ISO",
      "code_information": [
        {
          "code": "3600769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 384.8212,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 2868-20-014",
      "code_information": [
        {
          "code": "3601008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 108.9956,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-18800-49",
      "code_information": [
        {
          "code": "3601017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 232.4498,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2MM AO AR-18700-88",
      "code_information": [
        {
          "code": "3601047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 231.8937,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2010",
      "code_information": [
        {
          "code": "3601105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-RM 2.5X1150MM 351.708S",
      "code_information": [
        {
          "code": "3601122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 372.0309,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI 1.1MM AR-18700-06",
      "code_information": [
        {
          "code": "3601374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 165.7178,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-EXTERNAL TRL 1601",
      "code_information": [
        {
          "code": "3601977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 291.9525,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER 60°CVD 1600574",
      "code_information": [
        {
          "code": "3602108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 60.0588,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM LONG AR-8970-30L",
      "code_information": [
        {
          "code": "3602582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-1H WO/ATTC P45-920-0001",
      "code_information": [
        {
          "code": "3603021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 378.7041,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 4.5MM AR-8945-45C",
      "code_information": [
        {
          "code": "3603164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3603223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 41.7075,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INDUCTIVE HST NR340K9256",
      "code_information": [
        {
          "code": "3603913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 379.2602,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUCKLE-INDUCTIVE NR340B9256",
      "code_information": [
        {
          "code": "3603930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 113.4444,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.3 F/4.5MM MSN10006",
      "code_information": [
        {
          "code": "3604155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 398.1676,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK RC AR-3650DS",
      "code_information": [
        {
          "code": "3604296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 222.9961,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MARK OMNI H787137097015",
      "code_information": [
        {
          "code": "3604575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 111.22,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway HMO",
              "standard_charge_dollar": 1045.5305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FUNNEL-KELLER 2 HA-005",
      "code_information": [
        {
          "code": "3000004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 498.2656,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM     03.617.9xx",
      "code_information": [
        {
          "code": "3002371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT 2.9MM    18-82904",
      "code_information": [
        {
          "code": "3003237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 127.3469,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER     62-27015",
      "code_information": [
        {
          "code": "3003253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 347.0064,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO              CYB-x",
      "code_information": [
        {
          "code": "3003505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 72.293,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION xMM 5820-009-0xx",
      "code_information": [
        {
          "code": "3003845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 175.1715,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 29FR 96370-029",
      "code_information": [
        {
          "code": "3004237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 10M OMS-T10BT",
      "code_information": [
        {
          "code": "3005080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-OMEGA        1004930",
      "code_information": [
        {
          "code": "3009748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ENDO LINEAR       ATS45",
      "code_information": [
        {
          "code": "3009970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 238.0108,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-PERCUTANEOUS DRILL 324.213",
      "code_information": [
        {
          "code": "3012223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.50x",
      "code_information": [
        {
          "code": "3012358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 427.6409,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T7 TORX 703665",
      "code_information": [
        {
          "code": "3012408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 134.0201,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 4CHAN 8227411",
      "code_information": [
        {
          "code": "3012587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 305.2989,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-ROLLER 24FR WA22038C",
      "code_information": [
        {
          "code": "3012594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 206.8692,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE BLUNT 2867-05-220",
      "code_information": [
        {
          "code": "3016132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 173.5032,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONETTED       3101055",
      "code_information": [
        {
          "code": "3021160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 146.2543,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MULTIFIRE SCORPION",
      "code_information": [
        {
          "code": "3027390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 243.0157,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 11M VS101011P",
      "code_information": [
        {
          "code": "3027592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 333.66,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CARTER/MOORE      7959E",
      "code_information": [
        {
          "code": "3029197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 56.7222,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASOPORE  5400-020-008",
      "code_information": [
        {
          "code": "3029293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 353.6796,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICLE SCREW    9450019",
      "code_information": [
        {
          "code": "3034581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 112.3322,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60T GST60T",
      "code_information": [
        {
          "code": "3039946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 258.5865,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-SHORT BEVEL 35",
      "code_information": [
        {
          "code": "3058621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 245.7962,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED",
      "code_information": [
        {
          "code": "3058948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 130.6835,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 4.3MM",
      "code_information": [
        {
          "code": "3059085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 166.2739,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTASIS RESOLUTION 36",
      "code_information": [
        {
          "code": "3059208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 42.8197,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60BLUE GST60B",
      "code_information": [
        {
          "code": "3059280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 155.1519,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE DISP FIRSTPASS",
      "code_information": [
        {
          "code": "3060480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5",
      "code_information": [
        {
          "code": "3069109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 488.8119,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER MOD.TRINKLE",
      "code_information": [
        {
          "code": "3079260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 245.7962,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3081128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 330.3234,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE WHITE VASECR35",
      "code_information": [
        {
          "code": "3081553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 439.8751,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-MIDAS LEGEND ALL 14BAxxDC",
      "code_information": [
        {
          "code": "3084380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 291.9525,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12MM         B12LT",
      "code_information": [
        {
          "code": "3085209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 239.123,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DISP INSTRUMENT MINI S-TAK",
      "code_information": [
        {
          "code": "3085539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 124.0103,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-EXCEL LONG 12MM   B12XT",
      "code_information": [
        {
          "code": "3085625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 149.0348,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON         1806-0073S",
      "code_information": [
        {
          "code": "3085870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 176.8398,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST60G",
      "code_information": [
        {
          "code": "3086960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 452.1093,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TWIST DRILL 2.3 72203160",
      "code_information": [
        {
          "code": "3087938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 451.5532,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRPAE 3-ARM S.I.E.  420290",
      "code_information": [
        {
          "code": "3139015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-SURGICAL POWDER",
      "code_information": [
        {
          "code": "3526249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 7.7854,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE A0 XTV008001",
      "code_information": [
        {
          "code": "3526333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 63.3954,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC XI DYNJ905698",
      "code_information": [
        {
          "code": "3526424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 426.5287,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BARIATRIC DYNJ52366",
      "code_information": [
        {
          "code": "3526671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 61.7271,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3527286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 330.3234,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN 48630G",
      "code_information": [
        {
          "code": "3527883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-PLASMA STERILE   015",
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        {
          "code": "3541330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 88.976,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTRODUCER LOCALIZATION",
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        {
          "code": "3542520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 72.293,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANNULATED 5.0 705361",
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        {
          "code": "3547933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6X135MM 703691",
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        {
          "code": "3549125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ATSV II BE 8025H",
      "code_information": [
        {
          "code": "3549306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 298.6257,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PROFILE AR-1410LP",
      "code_information": [
        {
          "code": "3549310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 199.0838,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3549410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 311.9721,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-3.5 CAN DRILL AR-8956-35P",
      "code_information": [
        {
          "code": "3549430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 206.8692,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MINI SUTURE 72290128",
      "code_information": [
        {
          "code": "3549714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T8 TORX AO 703663",
      "code_information": [
        {
          "code": "3549847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 493.8168,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANNU STR",
      "code_information": [
        {
          "code": "3550047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 172.9471,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2009",
      "code_information": [
        {
          "code": "3550763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.6X130MM P99-110-2613",
      "code_information": [
        {
          "code": "3550773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO RESOLUTION 360",
      "code_information": [
        {
          "code": "3559020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 39.4831,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENFIT GJ FEEDING 18X45 825",
      "code_information": [
        {
          "code": "3559086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 126.7908,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-VAS",
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        {
          "code": "3559125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN W/AO 2.7MM 705250",
      "code_information": [
        {
          "code": "3559186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 339.7771,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8737-35",
      "code_information": [
        {
          "code": "3598175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 182.4008,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE SG CTI-10155G",
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        {
          "code": "3598399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 7.7854,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TI-KNOT 5MM 030404",
      "code_information": [
        {
          "code": "3598526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 285.2793,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X24MM 58850020",
      "code_information": [
        {
          "code": "3598638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 418.1872,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY",
      "code_information": [
        {
          "code": "3598673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 58.9466,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.6 CANN AR-8741-32",
      "code_information": [
        {
          "code": "3598694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 151.2592,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/170X80 03.133.103",
      "code_information": [
        {
          "code": "3599255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 181.2886,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVR 3.5X110 P99-110-3511",
      "code_information": [
        {
          "code": "3599772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 99.5419,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BONE BIOPSY CD1110",
      "code_information": [
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          "code": "3599838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-LK QR 10MMHEX P45-941-0002",
      "code_information": [
        {
          "code": "3600606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 149.5909,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.9 CANN AR-8741-25",
      "code_information": [
        {
          "code": "3600716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 219.1034,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUTERSINK-ISO MXM-074-ISO",
      "code_information": [
        {
          "code": "3600769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 384.8212,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 2868-20-014",
      "code_information": [
        {
          "code": "3601008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 108.9956,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-18800-49",
      "code_information": [
        {
          "code": "3601017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 232.4498,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2MM AO AR-18700-88",
      "code_information": [
        {
          "code": "3601047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 231.8937,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2010",
      "code_information": [
        {
          "code": "3601105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 207.4253,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-RM 2.5X1150MM 351.708S",
      "code_information": [
        {
          "code": "3601122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 372.0309,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI 1.1MM AR-18700-06",
      "code_information": [
        {
          "code": "3601374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 165.7178,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-EXTERNAL TRL 1601",
      "code_information": [
        {
          "code": "3601977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 291.9525,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER 60°CVD 1600574",
      "code_information": [
        {
          "code": "3602108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 60.0588,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM LONG AR-8970-30L",
      "code_information": [
        {
          "code": "3602582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-1H WO/ATTC P45-920-0001",
      "code_information": [
        {
          "code": "3603021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 378.7041,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 4.5MM AR-8945-45C",
      "code_information": [
        {
          "code": "3603164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 497.7095,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3603223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 41.7075,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INDUCTIVE HST NR340K9256",
      "code_information": [
        {
          "code": "3603913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 379.2602,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUCKLE-INDUCTIVE NR340B9256",
      "code_information": [
        {
          "code": "3603930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 113.4444,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.3 F/4.5MM MSN10006",
      "code_information": [
        {
          "code": "3604155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 398.1676,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK RC AR-3650DS",
      "code_information": [
        {
          "code": "3604296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 222.9961,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MARK OMNI H787137097015",
      "code_information": [
        {
          "code": "3604575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 111.22,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONTROLLER-AZUR DETACH 45-4001",
      "code_information": [
        {
          "code": "1411129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 3FR 0   390-103",
      "code_information": [
        {
          "code": "3002153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3889.9195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-1.3F NITINOL STONE",
      "code_information": [
        {
          "code": "3002170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 2.0",
      "code_information": [
        {
          "code": "3002254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1209.5175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0          357.407",
      "code_information": [
        {
          "code": "3002356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1989.7258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              316.286",
      "code_information": [
        {
          "code": "3002781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1655.5097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT ALL    18-84004HR",
      "code_information": [
        {
          "code": "3003228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2744.9096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACCESS 10 GAUGE",
      "code_information": [
        {
          "code": "3012102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1155.0197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SKYLINE 14MM   286820014",
      "code_information": [
        {
          "code": "3012132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING 3.5FR  370-115",
      "code_information": [
        {
          "code": "3013315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1142.7855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-EXTRA STRENGTH GRASPING",
      "code_information": [
        {
          "code": "3013324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2243.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERTER-SCREW T8   03.617.904",
      "code_information": [
        {
          "code": "3019821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1139.4489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE   28164Mx/3",
      "code_information": [
        {
          "code": "3019825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2981.2521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACIUM 30 CM TUNNELING TOOL",
      "code_information": [
        {
          "code": "3019908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1366.3377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KOH ALL",
      "code_information": [
        {
          "code": "3022136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1434.1819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STR COLD KNIFE K-SB",
      "code_information": [
        {
          "code": "3022228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM EYE WENTWORTH",
      "code_information": [
        {
          "code": "3029171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1392.4744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "QFIX-DISP SHOULDER 2.8MM",
      "code_information": [
        {
          "code": "3029223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1455.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STRT 302-431-000",
      "code_information": [
        {
          "code": "3034513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5897.4405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE0-FIAPC CIRCUMFRENTIAL",
      "code_information": [
        {
          "code": "3034521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1284.0349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60W       GST60W",
      "code_information": [
        {
          "code": "3039929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1146.1221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3040420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1692.2123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SM JOINT 2.4MM DRILL&GUID",
      "code_information": [
        {
          "code": "3058763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL WIDENING xMM",
      "code_information": [
        {
          "code": "3058871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7124.7532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR 200-120",
      "code_information": [
        {
          "code": "3059077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X216MM SHORT",
      "code_information": [
        {
          "code": "3059146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4823.6114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST45B",
      "code_information": [
        {
          "code": "3059269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45GREEN GST45G",
      "code_information": [
        {
          "code": "3059276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8426.0272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAG NARROW 116171",
      "code_information": [
        {
          "code": "3060498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PUSHLOCK 2.9  AR-1923DS",
      "code_information": [
        {
          "code": "3083078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3731.9871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI SLEEVE 32F 5232B",
      "code_information": [
        {
          "code": "3083150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1926.3304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PROGEL EXTENDED PGEN005-06",
      "code_information": [
        {
          "code": "3083771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 14081.5642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM         14MH30",
      "code_information": [
        {
          "code": "3084589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT INSTRUM 9733533XOM",
      "code_information": [
        {
          "code": "3084911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT PATIENT",
      "code_information": [
        {
          "code": "3084948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2211.6097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6 703702",
      "code_information": [
        {
          "code": "3087918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7526.2574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM 8MM JLATCH",
      "code_information": [
        {
          "code": "3526157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 152MM X 11GA",
      "code_information": [
        {
          "code": "3526203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW CANN HEX 2.5MM",
      "code_information": [
        {
          "code": "3526498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2073.1408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ASSIST CUSTOM BB10M33R",
      "code_information": [
        {
          "code": "3526535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4134.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION KNEE AR-12990",
      "code_information": [
        {
          "code": "3526976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EUS 19GA",
      "code_information": [
        {
          "code": "3526981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9711.7304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN DRILL 3.0X170MM 70535",
      "code_information": [
        {
          "code": "3526990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7167.5729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.4X150MM 702448",
      "code_information": [
        {
          "code": "3527149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6548.0775,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLACK GST45T",
      "code_information": [
        {
          "code": "3548010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION 14FR",
      "code_information": [
        {
          "code": "3549014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 0210",
      "code_information": [
        {
          "code": "3549040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON 50 PASSPORT",
      "code_information": [
        {
          "code": "3549108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP-50",
      "code_information": [
        {
          "code": "3549153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANN 3.0MM",
      "code_information": [
        {
          "code": "3549162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9536.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL HEARTSPAN",
      "code_information": [
        {
          "code": "3549177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP",
      "code_information": [
        {
          "code": "3549202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1486.4553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-BLADE 45-35015",
      "code_information": [
        {
          "code": "3549235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2951.2227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 703896",
      "code_information": [
        {
          "code": "3549240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4966.5291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X230MM 700355",
      "code_information": [
        {
          "code": "3549276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 10602.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACC-SELECTRA IC 50 392290",
      "code_information": [
        {
          "code": "3549414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5416.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X122MM 703897",
      "code_information": [
        {
          "code": "3549436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8520.0081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL J-HATCH 14MM",
      "code_information": [
        {
          "code": "3549445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 3.0MM",
      "code_information": [
        {
          "code": "3549453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SHAFT CANN 6192.0040",
      "code_information": [
        {
          "code": "3549723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3174.7749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 3.5X122MM 703694",
      "code_information": [
        {
          "code": "3549799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3549806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 4.3X216 705043",
      "code_information": [
        {
          "code": "3549844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAGNET-REPLACEMENT COCHLEAR",
      "code_information": [
        {
          "code": "3549900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.4X122MM 703696",
      "code_information": [
        {
          "code": "3549904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145 03.010.104",
      "code_information": [
        {
          "code": "3550057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-TENSIONER AR-5815",
      "code_information": [
        {
          "code": "3550191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5420.8628,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GJ 22 FR FEEDING 8660-22",
      "code_information": [
        {
          "code": "3550289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASCOPE-RHINOLARYNGO SLIM 51000",
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        {
          "code": "3550507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STIM 2862-02-203",
      "code_information": [
        {
          "code": "3550853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 11041.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4X195MM ST 315.40S",
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        {
          "code": "3550855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 29277.5528,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-INFUSION 8FR BIOFLO H787C",
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        {
          "code": "3550906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1978.0477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STERNAL 99-006-01-04",
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        {
          "code": "3559018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3981.676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 2.3X120MM",
      "code_information": [
        {
          "code": "3559139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15X45 XT SIG45AXT",
      "code_information": [
        {
          "code": "3559637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4925.9338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL VERACROSS",
      "code_information": [
        {
          "code": "3559675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1586.5533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM AR-8737-34",
      "code_information": [
        {
          "code": "3598007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 9912.4825,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PASS STIM DM-8225101",
      "code_information": [
        {
          "code": "3598049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 7374.4421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-14CC MIX ABS-2000",
      "code_information": [
        {
          "code": "3598068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5F 007250P",
      "code_information": [
        {
          "code": "3598088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y-SHAPE SHUNT FV015T",
      "code_information": [
        {
          "code": "3598131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1255.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HOOK/TRI BLADE 2056-6",
      "code_information": [
        {
          "code": "3598195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-915-3500",
      "code_information": [
        {
          "code": "3598232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2358.9762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5.5X60MM 58850055",
      "code_information": [
        {
          "code": "3598254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1246.7762,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SCALED 2X150MM 705134",
      "code_information": [
        {
          "code": "3598286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T TRACH SZ10 LT-510-S",
      "code_information": [
        {
          "code": "3598307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3857.6657,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-MINIONE M1-1-1824",
      "code_information": [
        {
          "code": "3598321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45",
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        {
          "code": "3598675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM AR-8737-58",
      "code_information": [
        {
          "code": "3598691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 535.3604,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT4.0 CA DRILL AR-8956C-40PD",
      "code_information": [
        {
          "code": "3598808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 535.3604,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X60MM 58850028",
      "code_information": [
        {
          "code": "3599257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-CANN 4MM 705260",
      "code_information": [
        {
          "code": "3599495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3409.4491,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.012",
      "code_information": [
        {
          "code": "3599540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1688.3196,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TALAR PEG 4MM IB200020",
      "code_information": [
        {
          "code": "3599675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM MR8-14MH30",
      "code_information": [
        {
          "code": "3599777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3775.3629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 400CC SSZ-X400",
      "code_information": [
        {
          "code": "3599825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3X100 MWM100",
      "code_information": [
        {
          "code": "3600385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 10446.8946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 3.5X160 P99-110-3516",
      "code_information": [
        {
          "code": "3600392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2640.9189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM CN DSDS1040",
      "code_information": [
        {
          "code": "3600691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB SMALL AR-18700-34",
      "code_information": [
        {
          "code": "3600865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2515.2403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-6.7MM CANN AR-8967-67C",
      "code_information": [
        {
          "code": "3601045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2926.7543,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X16MM 03.617.916",
      "code_information": [
        {
          "code": "3601076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2775.4951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM PC2-110135",
      "code_information": [
        {
          "code": "3601082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1960.8086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 P20-910-4000",
      "code_information": [
        {
          "code": "3601103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY EV10",
      "code_information": [
        {
          "code": "3601127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-14MM 86-0714",
      "code_information": [
        {
          "code": "3601253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3601317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 8783.5995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-2-0 ANCHOR W/CAN 4721",
      "code_information": [
        {
          "code": "3601325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2762.1487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-6.5-5.5X30 MOD 1119.1530",
      "code_information": [
        {
          "code": "3601579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-SHANNON 3MM P99-105-3080S",
      "code_information": [
        {
          "code": "3601619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3561.2644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AO AR-18700-58",
      "code_information": [
        {
          "code": "3602020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 6837.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HEX 2.5 MICA 57S02025",
      "code_information": [
        {
          "code": "3602089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.X220MM AO 703901",
      "code_information": [
        {
          "code": "3602150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2826.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE 3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3788.7093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATION-BIASURGE BAS-0101",
      "code_information": [
        {
          "code": "3602440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1735.5881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP CORAL 4.6MM",
      "code_information": [
        {
          "code": "3602602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CEMENT LL 2839-99-002",
      "code_information": [
        {
          "code": "3602865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL WIDENING 4MM 92141",
      "code_information": [
        {
          "code": "3603263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3611.8695,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X82 P65-105-3030-S",
      "code_information": [
        {
          "code": "3603433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 4037.286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2.5X8MM WHITE 48230W",
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        {
          "code": "3603758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X8MM GRAY 48230M",
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        {
          "code": "3603761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 34308.5895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-BL NEEDLE AR-7289",
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        {
          "code": "3603840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-STERNAL AR-7288T",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP DG 317.781",
      "code_information": [
        {
          "code": "3603899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1869.6082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QFIX 1.8MM 72290118",
      "code_information": [
        {
          "code": "3603977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FEN JT 2MM PIN MPDP0020",
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        {
          "code": "3604047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X100 P65-105-3031-S",
      "code_information": [
        {
          "code": "3604127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT TPT",
      "code_information": [
        {
          "code": "3604211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1944.1256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X200X100 P65-105-3020-S",
      "code_information": [
        {
          "code": "3604269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HD SCORPION AR-13999HDN",
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        {
          "code": "3604298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1843.4715,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TRC 3X370 AR-9091K-30",
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        {
          "code": "3604350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 535.3604,
          "maximum": 1586.5533,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-RELINE C 3990002",
      "code_information": [
        {
          "code": "3604439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 2243.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 4MM 5820-009-040",
      "code_information": [
        {
          "code": "3604573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE 28164MC-S",
      "code_information": [
        {
          "code": "3604595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1248.4445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-40",
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        {
          "code": "3604604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-STONE 1.9FR     390-105",
      "code_information": [
        {
          "code": "3002162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIPOFILTER-ASP CAN 25",
      "code_information": [
        {
          "code": "3002211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLUTED 4.0MM  315.40",
      "code_information": [
        {
          "code": "3002335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TIB DRILL 195MM     315.29",
      "code_information": [
        {
          "code": "3002367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 PERIPH SCREW",
      "code_information": [
        {
          "code": "3002369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5",
      "code_information": [
        {
          "code": "3002374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X230   1806-35xxS",
      "code_information": [
        {
          "code": "3002378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        72-2011",
      "code_information": [
        {
          "code": "3002384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 324.214",
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          "code": "3002392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM 702453",
      "code_information": [
        {
          "code": "3002396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
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              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8737-09",
      "code_information": [
        {
          "code": "3002398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 255589000",
      "code_information": [
        {
          "code": "3002401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.0 SCREW DRIVER",
      "code_information": [
        {
          "code": "3002656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1xMM 2868-20-01x",
      "code_information": [
        {
          "code": "3002771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SIZES     703xxx",
      "code_information": [
        {
          "code": "3002789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SZ   2883-01-xxx",
      "code_information": [
        {
          "code": "3012205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0          323.062",
      "code_information": [
        {
          "code": "3012319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          80-0387",
      "code_information": [
        {
          "code": "3012332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.103",
      "code_information": [
        {
          "code": "3012342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CTR INDIANA TOME  200060",
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        {
          "code": "3021156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE RGLR",
      "code_information": [
        {
          "code": "3029340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE XL",
      "code_information": [
        {
          "code": "3029342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-SCREW GUIDE      230790004",
      "code_information": [
        {
          "code": "3030620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PNEUMATIC ALL SZ  840-7s",
      "code_information": [
        {
          "code": "3034527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PRASS FLUSH TIP  8225101",
      "code_information": [
        {
          "code": "3034535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-ANASTOCLIP 4001-00",
      "code_information": [
        {
          "code": "3039801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GRAY     ECR45M",
      "code_information": [
        {
          "code": "3039879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.0 CANN DRI",
      "code_information": [
        {
          "code": "3040703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 3.0MM",
      "code_information": [
        {
          "code": "3058676",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6MM AR 8943-02",
      "code_information": [
        {
          "code": "3058783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL CONICAL 3+4MM",
      "code_information": [
        {
          "code": "3058870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM xxMM JLATC",
      "code_information": [
        {
          "code": "3059041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-HCS xxMM",
      "code_information": [
        {
          "code": "3059042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM XFO130022",
      "code_information": [
        {
          "code": "3059096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 15CMX2.2MM 15MH22",
      "code_information": [
        {
          "code": "3059107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X216MM SHORT",
      "code_information": [
        {
          "code": "3059144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE GST45W",
      "code_information": [
        {
          "code": "3059268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL MN60MA 00.0",
      "code_information": [
        {
          "code": "3060419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAGITTAL STD 116170",
      "code_information": [
        {
          "code": "3060497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 8",
      "code_information": [
        {
          "code": "3084826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL LONG 5MM      B5XT",
      "code_information": [
        {
          "code": "3085206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 7.5FR MEGA IAB",
      "code_information": [
        {
          "code": "3085536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 BLUE XI",
      "code_information": [
        {
          "code": "3186035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 GREEN XI",
      "code_information": [
        {
          "code": "3186037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRST 45 WHTE 48645W",
      "code_information": [
        {
          "code": "3186041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-EPISTAT XOMED    15-27031",
      "code_information": [
        {
          "code": "3507977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HELMET-PROTECTIVE SOFT A8000",
      "code_information": [
        {
          "code": "3519273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 102MM X 11GA",
      "code_information": [
        {
          "code": "3526202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO MEASURING 2.0X110MM",
      "code_information": [
        {
          "code": "3526234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO LONG 2.4X140MM",
      "code_information": [
        {
          "code": "3526301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-COMPLEX BREAST DYNJ60133",
      "code_information": [
        {
          "code": "3526421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-PURGE 043-0003",
      "code_information": [
        {
          "code": "3526914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER TORX 703667",
      "code_information": [
        {
          "code": "3527081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST PLEUREVAC A-9250LF",
      "code_information": [
        {
          "code": "3527083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-MICROBLATOR 30 AC4050-01",
      "code_information": [
        {
          "code": "3527275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM WHITE 47630W",
      "code_information": [
        {
          "code": "3527881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM BLUE 48630B",
      "code_information": [
        {
          "code": "3527882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION",
      "code_information": [
        {
          "code": "3549013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.0X135MM 703690",
      "code_information": [
        {
          "code": "3549128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 2.7X122MM 703695",
      "code_information": [
        {
          "code": "3549129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703880",
      "code_information": [
        {
          "code": "3549137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TORFLEX GUIDING",
      "code_information": [
        {
          "code": "3549175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL 10ML TWIN PK",
      "code_information": [
        {
          "code": "3549261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM CANN AR-1218-40",
      "code_information": [
        {
          "code": "3549308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 3.2 X 216 705",
      "code_information": [
        {
          "code": "3549843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PILOTED 6.0MM AR-1450",
      "code_information": [
        {
          "code": "3550002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR ACCESS 21030",
      "code_information": [
        {
          "code": "3550197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563010",
      "code_information": [
        {
          "code": "3550451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563020",
      "code_information": [
        {
          "code": "3550452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563030",
      "code_information": [
        {
          "code": "3550453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563040",
      "code_information": [
        {
          "code": "3550454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERC INSERT AR-1923PK",
      "code_information": [
        {
          "code": "3550583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP 3 BAG SPIKE BLOOD IV",
      "code_information": [
        {
          "code": "3550718",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-910-3500",
      "code_information": [
        {
          "code": "3550772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.3X100MM P99-100-1310",
      "code_information": [
        {
          "code": "3559004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X12MM VASC SIG30TAV",
      "code_information": [
        {
          "code": "3559124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 16FR 98437",
      "code_information": [
        {
          "code": "3559429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LARYNGOSCOPE-CMOS IDEO RHINO",
      "code_information": [
        {
          "code": "3559674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-NAVIGATION TDNC001",
      "code_information": [
        {
          "code": "3559689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE DBL ABS-10010S",
      "code_information": [
        {
          "code": "3598066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACP+ACD-A ABS-10011T",
      "code_information": [
        {
          "code": "3598067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI FT CMP AR-8737-41",
      "code_information": [
        {
          "code": "3598177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X60MM 58850025",
      "code_information": [
        {
          "code": "3598253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X14MM 03.617.914",
      "code_information": [
        {
          "code": "3598581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T25 PERIP 5901-1128",
      "code_information": [
        {
          "code": "3599025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 32FR 5532S",
      "code_information": [
        {
          "code": "3599075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 40FR 5540B",
      "code_information": [
        {
          "code": "3599076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8X200MM 03.133.108",
      "code_information": [
        {
          "code": "3599159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/110X30MM 03.133.100",
      "code_information": [
        {
          "code": "3599236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/140X60MM 03.133.101",
      "code_information": [
        {
          "code": "3599240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/170X80 03.133.107",
      "code_information": [
        {
          "code": "3599241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 4.2X120 P99-100-421",
      "code_information": [
        {
          "code": "3599394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X130 1806-3550S",
      "code_information": [
        {
          "code": "3599470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STERILE PERC 150MM 9733236",
      "code_information": [
        {
          "code": "3599775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 2MM MR8-15MH22",
      "code_information": [
        {
          "code": "3599776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 545CC SSZ-X545",
      "code_information": [
        {
          "code": "3599822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 485CC SSZ-F485",
      "code_information": [
        {
          "code": "3599823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 365CC SSZ-F365",
      "code_information": [
        {
          "code": "3599824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT DPT5",
      "code_information": [
        {
          "code": "3599926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM AR-18800-19",
      "code_information": [
        {
          "code": "3600284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-NANO 125MM AR-3210-0053",
      "code_information": [
        {
          "code": "3600399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3600410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM SHRT AR-18800-18",
      "code_information": [
        {
          "code": "3600411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CN 2MM AR-8610DB-30C",
      "code_information": [
        {
          "code": "3600487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X140MM P99-100-2814",
      "code_information": [
        {
          "code": "3600522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.4X95MM P45-960-2495",
      "code_information": [
        {
          "code": "3600612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-18700-20",
      "code_information": [
        {
          "code": "3600864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM AR-8945-30C",
      "code_information": [
        {
          "code": "3600872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-8967-40C",
      "code_information": [
        {
          "code": "3600876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.5MM 56014500",
      "code_information": [
        {
          "code": "3600979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 2868-20-012",
      "code_information": [
        {
          "code": "3600982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X150 5028-8-150",
      "code_information": [
        {
          "code": "3600991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X300 5028-8-300",
      "code_information": [
        {
          "code": "3600992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM LG AR-18800-16",
      "code_information": [
        {
          "code": "3601015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3601016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.9X140 P99-110-2914",
      "code_information": [
        {
          "code": "3601117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-12MM 86-0712",
      "code_information": [
        {
          "code": "3601252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLER BLACK 45 48345T",
      "code_information": [
        {
          "code": "3601353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL ENFIT",
      "code_information": [
        {
          "code": "3601439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X160MM P99-100-2816",
      "code_information": [
        {
          "code": "3601457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.6X160MM P99-100-3616",
      "code_information": [
        {
          "code": "3601458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2/SRT AR-18700-89",
      "code_information": [
        {
          "code": "3601712",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.7MM CSS-072-47-SQ",
      "code_information": [
        {
          "code": "3601732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.1X160MM P99-100-3116",
      "code_information": [
        {
          "code": "3601958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP PEARL 5.7MM",
      "code_information": [
        {
          "code": "3602601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DRILL W/NEEDLE 72205692",
      "code_information": [
        {
          "code": "3602934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-UNI PIN P45-970-2000",
      "code_information": [
        {
          "code": "3602946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BLUNT 4X45M P45-196-5045",
      "code_information": [
        {
          "code": "3602947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.4X160MM P45-960-3416",
      "code_information": [
        {
          "code": "3602948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-5MM HLF PN P45-925-0105",
      "code_information": [
        {
          "code": "3603024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3603100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER DOME 7MM P20-070-WD00",
      "code_information": [
        {
          "code": "3603132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL LG 2.4X160M P99-100-2416",
      "code_information": [
        {
          "code": "3603134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2X8X72 P65-105-2008-S",
      "code_information": [
        {
          "code": "3603436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-3.5X8MM BLUE 48230B",
      "code_information": [
        {
          "code": "3603757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.7 FOOTPRINT 72205888",
      "code_information": [
        {
          "code": "3603793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-PLATE TEMP 705019",
      "code_information": [
        {
          "code": "3603817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP 388.174",
      "code_information": [
        {
          "code": "3603898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW T20 57DRVT20",
      "code_information": [
        {
          "code": "3603903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.6 F/4MM MSN10012",
      "code_information": [
        {
          "code": "3604051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM AR-4160-24",
      "code_information": [
        {
          "code": "3604150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STIM 8225401",
      "code_information": [
        {
          "code": "3604210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLV 1.8X400 643518400",
      "code_information": [
        {
          "code": "3604331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-SMTH 1.8X400 641018400",
      "code_information": [
        {
          "code": "3604332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 1.7X120 P99-110-1712",
      "code_information": [
        {
          "code": "3604378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO 2.2F/115 CYB-2",
      "code_information": [
        {
          "code": "3604566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 3MM 5820-009-030",
      "code_information": [
        {
          "code": "3604572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UTERINE 30 KC-RUMI-30",
      "code_information": [
        {
          "code": "3604602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-25",
      "code_information": [
        {
          "code": "3604603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1566,
          "minimum": 535.3604,
          "maximum": 1136.4462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 795.5123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONTROLLER-AZUR DETACH 45-4001",
      "code_information": [
        {
          "code": "1411129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FUNNEL-KELLER 2 HA-005",
      "code_information": [
        {
          "code": "3000004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 3FR 0   390-103",
      "code_information": [
        {
          "code": "3002153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-STONE 1.9FR     390-105",
      "code_information": [
        {
          "code": "3002162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-1.3F NITINOL STONE",
      "code_information": [
        {
          "code": "3002170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIPOFILTER-ASP CAN 25",
      "code_information": [
        {
          "code": "3002211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 2.0",
      "code_information": [
        {
          "code": "3002254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLUTED 4.0MM  315.40",
      "code_information": [
        {
          "code": "3002335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0          357.407",
      "code_information": [
        {
          "code": "3002356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TIB DRILL 195MM     315.29",
      "code_information": [
        {
          "code": "3002367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 PERIPH SCREW",
      "code_information": [
        {
          "code": "3002369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM     03.617.9xx",
      "code_information": [
        {
          "code": "3002371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5",
      "code_information": [
        {
          "code": "3002374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X230   1806-35xxS",
      "code_information": [
        {
          "code": "3002378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        72-2011",
      "code_information": [
        {
          "code": "3002384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 324.214",
      "code_information": [
        {
          "code": "3002392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM 702453",
      "code_information": [
        {
          "code": "3002396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8737-09",
      "code_information": [
        {
          "code": "3002398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 255589000",
      "code_information": [
        {
          "code": "3002401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.0 SCREW DRIVER",
      "code_information": [
        {
          "code": "3002656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1xMM 2868-20-01x",
      "code_information": [
        {
          "code": "3002771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              316.286",
      "code_information": [
        {
          "code": "3002781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SIZES     703xxx",
      "code_information": [
        {
          "code": "3002789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT ALL    18-84004HR",
      "code_information": [
        {
          "code": "3003228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT 2.9MM    18-82904",
      "code_information": [
        {
          "code": "3003237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER     62-27015",
      "code_information": [
        {
          "code": "3003253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO              CYB-x",
      "code_information": [
        {
          "code": "3003505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION xMM 5820-009-0xx",
      "code_information": [
        {
          "code": "3003845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 29FR 96370-029",
      "code_information": [
        {
          "code": "3004237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 10M OMS-T10BT",
      "code_information": [
        {
          "code": "3005080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-OMEGA        1004930",
      "code_information": [
        {
          "code": "3009748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ENDO LINEAR       ATS45",
      "code_information": [
        {
          "code": "3009970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACCESS 10 GAUGE",
      "code_information": [
        {
          "code": "3012102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SKYLINE 14MM   286820014",
      "code_information": [
        {
          "code": "3012132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ALL SZ   2883-01-xxx",
      "code_information": [
        {
          "code": "3012205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-PERCUTANEOUS DRILL 324.213",
      "code_information": [
        {
          "code": "3012223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0          323.062",
      "code_information": [
        {
          "code": "3012319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          80-0387",
      "code_information": [
        {
          "code": "3012332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.103",
      "code_information": [
        {
          "code": "3012342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.50x",
      "code_information": [
        {
          "code": "3012358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T7 TORX 703665",
      "code_information": [
        {
          "code": "3012408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 4CHAN 8227411",
      "code_information": [
        {
          "code": "3012587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-ROLLER 24FR WA22038C",
      "code_information": [
        {
          "code": "3012594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING 3.5FR  370-115",
      "code_information": [
        {
          "code": "3013315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-EXTRA STRENGTH GRASPING",
      "code_information": [
        {
          "code": "3013324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE BLUNT 2867-05-220",
      "code_information": [
        {
          "code": "3016132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERTER-SCREW T8   03.617.904",
      "code_information": [
        {
          "code": "3019821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE   28164Mx/3",
      "code_information": [
        {
          "code": "3019825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACIUM 30 CM TUNNELING TOOL",
      "code_information": [
        {
          "code": "3019908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CTR INDIANA TOME  200060",
      "code_information": [
        {
          "code": "3021156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONETTED       3101055",
      "code_information": [
        {
          "code": "3021160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KOH ALL",
      "code_information": [
        {
          "code": "3022136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STR COLD KNIFE K-SB",
      "code_information": [
        {
          "code": "3022228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MULTIFIRE SCORPION",
      "code_information": [
        {
          "code": "3027390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 11M VS101011P",
      "code_information": [
        {
          "code": "3027592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM EYE WENTWORTH",
      "code_information": [
        {
          "code": "3029171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CARTER/MOORE      7959E",
      "code_information": [
        {
          "code": "3029197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "QFIX-DISP SHOULDER 2.8MM",
      "code_information": [
        {
          "code": "3029223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASOPORE  5400-020-008",
      "code_information": [
        {
          "code": "3029293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE RGLR",
      "code_information": [
        {
          "code": "3029340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-LAPARSCOPIC SUTURE XL",
      "code_information": [
        {
          "code": "3029342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-SCREW GUIDE      230790004",
      "code_information": [
        {
          "code": "3030620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STRT 302-431-000",
      "code_information": [
        {
          "code": "3034513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE0-FIAPC CIRCUMFRENTIAL",
      "code_information": [
        {
          "code": "3034521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PNEUMATIC ALL SZ  840-7s",
      "code_information": [
        {
          "code": "3034527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PRASS FLUSH TIP  8225101",
      "code_information": [
        {
          "code": "3034535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICLE SCREW    9450019",
      "code_information": [
        {
          "code": "3034581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-ANASTOCLIP 4001-00",
      "code_information": [
        {
          "code": "3039801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GRAY     ECR45M",
      "code_information": [
        {
          "code": "3039879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60W       GST60W",
      "code_information": [
        {
          "code": "3039929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60T GST60T",
      "code_information": [
        {
          "code": "3039946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3040420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.0 CANN DRI",
      "code_information": [
        {
          "code": "3040703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-SHORT BEVEL 35",
      "code_information": [
        {
          "code": "3058621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 3.0MM",
      "code_information": [
        {
          "code": "3058676",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SM JOINT 2.4MM DRILL&GUID",
      "code_information": [
        {
          "code": "3058763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6MM AR 8943-02",
      "code_information": [
        {
          "code": "3058783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL CONICAL 3+4MM",
      "code_information": [
        {
          "code": "3058870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL WIDENING xMM",
      "code_information": [
        {
          "code": "3058871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED",
      "code_information": [
        {
          "code": "3058948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM xxMM JLATC",
      "code_information": [
        {
          "code": "3059041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-HCS xxMM",
      "code_information": [
        {
          "code": "3059042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR 200-120",
      "code_information": [
        {
          "code": "3059077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 4.3MM",
      "code_information": [
        {
          "code": "3059085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM XFO130022",
      "code_information": [
        {
          "code": "3059096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 15CMX2.2MM 15MH22",
      "code_information": [
        {
          "code": "3059107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X216MM SHORT",
      "code_information": [
        {
          "code": "3059144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X216MM SHORT",
      "code_information": [
        {
          "code": "3059146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTASIS RESOLUTION 36",
      "code_information": [
        {
          "code": "3059208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE GST45W",
      "code_information": [
        {
          "code": "3059268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST45B",
      "code_information": [
        {
          "code": "3059269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45GREEN GST45G",
      "code_information": [
        {
          "code": "3059276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60BLUE GST60B",
      "code_information": [
        {
          "code": "3059280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL MN60MA 00.0",
      "code_information": [
        {
          "code": "3060419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE DISP FIRSTPASS",
      "code_information": [
        {
          "code": "3060480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAGITTAL STD 116170",
      "code_information": [
        {
          "code": "3060497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MAKO SAG NARROW 116171",
      "code_information": [
        {
          "code": "3060498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5",
      "code_information": [
        {
          "code": "3069109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER MOD.TRINKLE",
      "code_information": [
        {
          "code": "3079260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3081128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE WHITE VASECR35",
      "code_information": [
        {
          "code": "3081553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PUSHLOCK 2.9  AR-1923DS",
      "code_information": [
        {
          "code": "3083078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI SLEEVE 32F 5232B",
      "code_information": [
        {
          "code": "3083150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PROGEL EXTENDED PGEN005-06",
      "code_information": [
        {
          "code": "3083771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-MIDAS LEGEND ALL 14BAxxDC",
      "code_information": [
        {
          "code": "3084380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM         14MH30",
      "code_information": [
        {
          "code": "3084589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 8",
      "code_information": [
        {
          "code": "3084826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT INSTRUM 9733533XOM",
      "code_information": [
        {
          "code": "3084911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-ENT PATIENT",
      "code_information": [
        {
          "code": "3084948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL LONG 5MM      B5XT",
      "code_information": [
        {
          "code": "3085206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12MM         B12LT",
      "code_information": [
        {
          "code": "3085209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 7.5FR MEGA IAB",
      "code_information": [
        {
          "code": "3085536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DISP INSTRUMENT MINI S-TAK",
      "code_information": [
        {
          "code": "3085539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-EXCEL LONG 12MM   B12XT",
      "code_information": [
        {
          "code": "3085625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON         1806-0073S",
      "code_information": [
        {
          "code": "3085870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE GST60G",
      "code_information": [
        {
          "code": "3086960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6 703702",
      "code_information": [
        {
          "code": "3087918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-TWIST DRILL 2.3 72203160",
      "code_information": [
        {
          "code": "3087938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRPAE 3-ARM S.I.E.  420290",
      "code_information": [
        {
          "code": "3139015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 BLUE XI",
      "code_information": [
        {
          "code": "3186035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRIST 45 GREEN XI",
      "code_information": [
        {
          "code": "3186037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOWRST 45 WHTE 48645W",
      "code_information": [
        {
          "code": "3186041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-EPISTAT XOMED    15-27031",
      "code_information": [
        {
          "code": "3507977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HELMET-PROTECTIVE SOFT A8000",
      "code_information": [
        {
          "code": "3519273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X135MM 8MM JLATCH",
      "code_information": [
        {
          "code": "3526157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 102MM X 11GA",
      "code_information": [
        {
          "code": "3526202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY 152MM X 11GA",
      "code_information": [
        {
          "code": "3526203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO MEASURING 2.0X110MM",
      "code_information": [
        {
          "code": "3526234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-SURGICAL POWDER",
      "code_information": [
        {
          "code": "3526249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO LONG 2.4X140MM",
      "code_information": [
        {
          "code": "3526301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE A0 XTV008001",
      "code_information": [
        {
          "code": "3526333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-COMPLEX BREAST DYNJ60133",
      "code_information": [
        {
          "code": "3526421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC XI DYNJ905698",
      "code_information": [
        {
          "code": "3526424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-NEURO DYNJ60135",
      "code_information": [
        {
          "code": "3526427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW CANN HEX 2.5MM",
      "code_information": [
        {
          "code": "3526498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ASSIST CUSTOM BB10M33R",
      "code_information": [
        {
          "code": "3526535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BARIATRIC DYNJ52366",
      "code_information": [
        {
          "code": "3526671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-PURGE 043-0003",
      "code_information": [
        {
          "code": "3526914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION KNEE AR-12990",
      "code_information": [
        {
          "code": "3526976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EUS 19GA",
      "code_information": [
        {
          "code": "3526981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN DRILL 3.0X170MM 70535",
      "code_information": [
        {
          "code": "3526990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER TORX 703667",
      "code_information": [
        {
          "code": "3527081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST PLEUREVAC A-9250LF",
      "code_information": [
        {
          "code": "3527083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.4X150MM 702448",
      "code_information": [
        {
          "code": "3527149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-MICROBLATOR 30 AC4050-01",
      "code_information": [
        {
          "code": "3527275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SMR BIPOLAR TYPEA",
      "code_information": [
        {
          "code": "3527286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM WHITE 47630W",
      "code_information": [
        {
          "code": "3527881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM BLUE 48630B",
      "code_information": [
        {
          "code": "3527882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN 48630G",
      "code_information": [
        {
          "code": "3527883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-PLASMA STERILE   015",
      "code_information": [
        {
          "code": "3541330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTRODUCER LOCALIZATION",
      "code_information": [
        {
          "code": "3542520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANNULATED 5.0 705361",
      "code_information": [
        {
          "code": "3547933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLACK GST45T",
      "code_information": [
        {
          "code": "3548010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION",
      "code_information": [
        {
          "code": "3549013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RETROGRADE INTUBATION 14FR",
      "code_information": [
        {
          "code": "3549014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 0210",
      "code_information": [
        {
          "code": "3549040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON 50 PASSPORT",
      "code_information": [
        {
          "code": "3549108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.6X135MM 703691",
      "code_information": [
        {
          "code": "3549125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.0X135MM 703690",
      "code_information": [
        {
          "code": "3549128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 2.7X122MM 703695",
      "code_information": [
        {
          "code": "3549129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703880",
      "code_information": [
        {
          "code": "3549137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP-50",
      "code_information": [
        {
          "code": "3549153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANN 3.0MM",
      "code_information": [
        {
          "code": "3549162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TORFLEX GUIDING",
      "code_information": [
        {
          "code": "3549175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL HEARTSPAN",
      "code_information": [
        {
          "code": "3549177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PRO AR-1409LP",
      "code_information": [
        {
          "code": "3549202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-BLADE 45-35015",
      "code_information": [
        {
          "code": "3549235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 703896",
      "code_information": [
        {
          "code": "3549240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL 10ML TWIN PK",
      "code_information": [
        {
          "code": "3549261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X230MM 700355",
      "code_information": [
        {
          "code": "3549276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ATSV II BE 8025H",
      "code_information": [
        {
          "code": "3549306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM CANN AR-1218-40",
      "code_information": [
        {
          "code": "3549308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LOW PROFILE AR-1410LP",
      "code_information": [
        {
          "code": "3549310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3549410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACC-SELECTRA IC 50 392290",
      "code_information": [
        {
          "code": "3549414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-3.5 CAN DRILL AR-8956-35P",
      "code_information": [
        {
          "code": "3549430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X122MM 703897",
      "code_information": [
        {
          "code": "3549436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL J-HATCH 14MM",
      "code_information": [
        {
          "code": "3549445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 3.0MM",
      "code_information": [
        {
          "code": "3549453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MINI SUTURE 72290128",
      "code_information": [
        {
          "code": "3549714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SHAFT CANN 6192.0040",
      "code_information": [
        {
          "code": "3549723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- OVER 3.5X122MM 703694",
      "code_information": [
        {
          "code": "3549799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3549806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 3.2 X 216 705",
      "code_information": [
        {
          "code": "3549843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHORT 4.3X216 705043",
      "code_information": [
        {
          "code": "3549844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-T8 TORX AO 703663",
      "code_information": [
        {
          "code": "3549847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAGNET-REPLACEMENT COCHLEAR",
      "code_information": [
        {
          "code": "3549900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.4X122MM 703696",
      "code_information": [
        {
          "code": "3549904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PILOTED 6.0MM AR-1450",
      "code_information": [
        {
          "code": "3550002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREWDRIVER-CANNU STR",
      "code_information": [
        {
          "code": "3550047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145 03.010.104",
      "code_information": [
        {
          "code": "3550057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-TENSIONER AR-5815",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR ACCESS 21030",
      "code_information": [
        {
          "code": "3550197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GJ 22 FR FEEDING 8660-22",
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        {
          "code": "3550289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563010",
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        {
          "code": "3550451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563020",
      "code_information": [
        {
          "code": "3550452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563030",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00563040",
      "code_information": [
        {
          "code": "3550454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASCOPE-RHINOLARYNGO SLIM 51000",
      "code_information": [
        {
          "code": "3550507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERC INSERT AR-1923PK",
      "code_information": [
        {
          "code": "3550583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP 3 BAG SPIKE BLOOD IV",
      "code_information": [
        {
          "code": "3550718",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2009",
      "code_information": [
        {
          "code": "3550763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-910-3500",
      "code_information": [
        {
          "code": "3550772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.6X130MM P99-110-2613",
      "code_information": [
        {
          "code": "3550773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STIM 2862-02-203",
      "code_information": [
        {
          "code": "3550853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4X195MM ST 315.40S",
      "code_information": [
        {
          "code": "3550855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-INFUSION 8FR BIOFLO H787C",
      "code_information": [
        {
          "code": "3550906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.3X100MM P99-100-1310",
      "code_information": [
        {
          "code": "3559004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STERNAL 99-006-01-04",
      "code_information": [
        {
          "code": "3559018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO RESOLUTION 360",
      "code_information": [
        {
          "code": "3559020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENFIT GJ FEEDING 18X45 825",
      "code_information": [
        {
          "code": "3559086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X12MM VASC SIG30TAV",
      "code_information": [
        {
          "code": "3559124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-VAS",
      "code_information": [
        {
          "code": "3559125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 2.3X120MM",
      "code_information": [
        {
          "code": "3559139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN W/AO 2.7MM 705250",
      "code_information": [
        {
          "code": "3559186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 16FR 98437",
      "code_information": [
        {
          "code": "3559429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15X45 XT SIG45AXT",
      "code_information": [
        {
          "code": "3559637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LARYNGOSCOPE-CMOS IDEO RHINO",
      "code_information": [
        {
          "code": "3559674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TRANSSEPTAL VERACROSS",
      "code_information": [
        {
          "code": "3559675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-NAVIGATION TDNC001",
      "code_information": [
        {
          "code": "3559689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM AR-8737-34",
      "code_information": [
        {
          "code": "3598007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PASS STIM DM-8225101",
      "code_information": [
        {
          "code": "3598049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE DBL ABS-10010S",
      "code_information": [
        {
          "code": "3598066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACP+ACD-A ABS-10011T",
      "code_information": [
        {
          "code": "3598067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-14CC MIX ABS-2000",
      "code_information": [
        {
          "code": "3598068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5F 007250P",
      "code_information": [
        {
          "code": "3598088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y-SHAPE SHUNT FV015T",
      "code_information": [
        {
          "code": "3598131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8737-35",
      "code_information": [
        {
          "code": "3598175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI FT CMP AR-8737-41",
      "code_information": [
        {
          "code": "3598177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HOOK/TRI BLADE 2056-6",
      "code_information": [
        {
          "code": "3598195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.5 P20-915-3500",
      "code_information": [
        {
          "code": "3598232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X60MM 58850025",
      "code_information": [
        {
          "code": "3598253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5.5X60MM 58850055",
      "code_information": [
        {
          "code": "3598254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SCALED 2X150MM 705134",
      "code_information": [
        {
          "code": "3598286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T TRACH SZ10 LT-510-S",
      "code_information": [
        {
          "code": "3598307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-MINIONE M1-1-1824",
      "code_information": [
        {
          "code": "3598321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE SG CTI-10155G",
      "code_information": [
        {
          "code": "3598399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TI-KNOT 5MM 030404",
      "code_information": [
        {
          "code": "3598526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X14MM 03.617.914",
      "code_information": [
        {
          "code": "3598581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X24MM 58850020",
      "code_information": [
        {
          "code": "3598638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY",
      "code_information": [
        {
          "code": "3598673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45",
      "code_information": [
        {
          "code": "3598675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2MM AR-8737-58",
      "code_information": [
        {
          "code": "3598691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.6 CANN AR-8741-32",
      "code_information": [
        {
          "code": "3598694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT4.0 CA DRILL AR-8956C-40PD",
      "code_information": [
        {
          "code": "3598808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T25 PERIP 5901-1128",
      "code_information": [
        {
          "code": "3599025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 32FR 5532S",
      "code_information": [
        {
          "code": "3599075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VISIGI 40FR 5540B",
      "code_information": [
        {
          "code": "3599076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8X200MM 03.133.108",
      "code_information": [
        {
          "code": "3599159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/110X30MM 03.133.100",
      "code_information": [
        {
          "code": "3599236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2/140X60MM 03.133.101",
      "code_information": [
        {
          "code": "3599240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/170X80 03.133.107",
      "code_information": [
        {
          "code": "3599241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/170X80 03.133.103",
      "code_information": [
        {
          "code": "3599255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X60MM 58850028",
      "code_information": [
        {
          "code": "3599257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 4.2X120 P99-100-421",
      "code_information": [
        {
          "code": "3599394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X130 1806-3550S",
      "code_information": [
        {
          "code": "3599470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-CANN 4MM 705260",
      "code_information": [
        {
          "code": "3599495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.012",
      "code_information": [
        {
          "code": "3599540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TALAR PEG 4MM IB200020",
      "code_information": [
        {
          "code": "3599675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVR 3.5X110 P99-110-3511",
      "code_information": [
        {
          "code": "3599772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STERILE PERC 150MM 9733236",
      "code_information": [
        {
          "code": "3599775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 2MM MR8-15MH22",
      "code_information": [
        {
          "code": "3599776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LEGEND 3MM MR8-14MH30",
      "code_information": [
        {
          "code": "3599777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 545CC SSZ-X545",
      "code_information": [
        {
          "code": "3599822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 485CC SSZ-F485",
      "code_information": [
        {
          "code": "3599823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-FULLPROF 365CC SSZ-F365",
      "code_information": [
        {
          "code": "3599824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-X-FULL 400CC SSZ-X400",
      "code_information": [
        {
          "code": "3599825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BONE BIOPSY CD1110",
      "code_information": [
        {
          "code": "3599838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT DPT5",
      "code_information": [
        {
          "code": "3599926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM AR-18800-19",
      "code_information": [
        {
          "code": "3600284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3X100 MWM100",
      "code_information": [
        {
          "code": "3600385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 3.5X160 P99-110-3516",
      "code_information": [
        {
          "code": "3600392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-NANO 125MM AR-3210-0053",
      "code_information": [
        {
          "code": "3600399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3600410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM SHRT AR-18800-18",
      "code_information": [
        {
          "code": "3600411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CN 2MM AR-8610DB-30C",
      "code_information": [
        {
          "code": "3600487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X140MM P99-100-2814",
      "code_information": [
        {
          "code": "3600522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-LK QR 10MMHEX P45-941-0002",
      "code_information": [
        {
          "code": "3600606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.4X95MM P45-960-2495",
      "code_information": [
        {
          "code": "3600612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM CN DSDS1040",
      "code_information": [
        {
          "code": "3600691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.9 CANN AR-8741-25",
      "code_information": [
        {
          "code": "3600716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUTERSINK-ISO MXM-074-ISO",
      "code_information": [
        {
          "code": "3600769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-18700-20",
      "code_information": [
        {
          "code": "3600864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB SMALL AR-18700-34",
      "code_information": [
        {
          "code": "3600865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM AR-8945-30C",
      "code_information": [
        {
          "code": "3600872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-8967-40C",
      "code_information": [
        {
          "code": "3600876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.5MM 56014500",
      "code_information": [
        {
          "code": "3600979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 2868-20-012",
      "code_information": [
        {
          "code": "3600982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X150 5028-8-150",
      "code_information": [
        {
          "code": "3600991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 8X300 5028-8-300",
      "code_information": [
        {
          "code": "3600992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 2868-20-014",
      "code_information": [
        {
          "code": "3601008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM LG AR-18800-16",
      "code_information": [
        {
          "code": "3601015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AO AR-18800-01",
      "code_information": [
        {
          "code": "3601016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-18800-49",
      "code_information": [
        {
          "code": "3601017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-6.7MM CANN AR-8967-67C",
      "code_information": [
        {
          "code": "3601045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2MM AO AR-18700-88",
      "code_information": [
        {
          "code": "3601047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL QC 2X16MM 03.617.916",
      "code_information": [
        {
          "code": "3601076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM PC2-110135",
      "code_information": [
        {
          "code": "3601082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 P20-910-4000",
      "code_information": [
        {
          "code": "3601103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-BONE P99-100-2010",
      "code_information": [
        {
          "code": "3601105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.9X140 P99-110-2914",
      "code_information": [
        {
          "code": "3601117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-RM 2.5X1150MM 351.708S",
      "code_information": [
        {
          "code": "3601122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ELEVATION BIOPSY EV10",
      "code_information": [
        {
          "code": "3601127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-12MM 86-0712",
      "code_information": [
        {
          "code": "3601252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-14MM 86-0714",
      "code_information": [
        {
          "code": "3601253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3601317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-2-0 ANCHOR W/CAN 4721",
      "code_information": [
        {
          "code": "3601325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLER BLACK 45 48345T",
      "code_information": [
        {
          "code": "3601353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MINI 1.1MM AR-18700-06",
      "code_information": [
        {
          "code": "3601374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL ENFIT",
      "code_information": [
        {
          "code": "3601439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8X160MM P99-100-2816",
      "code_information": [
        {
          "code": "3601457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.6X160MM P99-100-3616",
      "code_information": [
        {
          "code": "3601458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-6.5-5.5X30 MOD 1119.1530",
      "code_information": [
        {
          "code": "3601579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-SHANNON 3MM P99-105-3080S",
      "code_information": [
        {
          "code": "3601619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.2/SRT AR-18700-89",
      "code_information": [
        {
          "code": "3601712",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.7MM CSS-072-47-SQ",
      "code_information": [
        {
          "code": "3601732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.1X160MM P99-100-3116",
      "code_information": [
        {
          "code": "3601958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-EXTERNAL TRL 1601",
      "code_information": [
        {
          "code": "3601977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AO AR-18700-58",
      "code_information": [
        {
          "code": "3602020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HEX 2.5 MICA 57S02025",
      "code_information": [
        {
          "code": "3602089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER 60°CVD 1600574",
      "code_information": [
        {
          "code": "3602108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.X220MM AO 703901",
      "code_information": [
        {
          "code": "3602150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 4L CN AR-8973-40LS",
      "code_information": [
        {
          "code": "3602351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE 3MM XL PEDICLE 4056-00",
      "code_information": [
        {
          "code": "3602386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE TEFLON NSTRL 1806-0073",
      "code_information": [
        {
          "code": "3602396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATION-BIASURGE BAS-0101",
      "code_information": [
        {
          "code": "3602440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 3MM LONG AR-8970-30L",
      "code_information": [
        {
          "code": "3602582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP PEARL 5.7MM",
      "code_information": [
        {
          "code": "3602601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HYSTEROSCOPE-DISP CORAL 4.6MM",
      "code_information": [
        {
          "code": "3602602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CEMENT LL 2839-99-002",
      "code_information": [
        {
          "code": "3602865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DRILL W/NEEDLE 72205692",
      "code_information": [
        {
          "code": "3602934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-UNI PIN P45-970-2000",
      "code_information": [
        {
          "code": "3602946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BLUNT 4X45M P45-196-5045",
      "code_information": [
        {
          "code": "3602947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.4X160MM P45-960-3416",
      "code_information": [
        {
          "code": "3602948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-1H WO/ATTC P45-920-0001",
      "code_information": [
        {
          "code": "3603021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-5MM HLF PN P45-925-0105",
      "code_information": [
        {
          "code": "3603024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-90 COBLATION 72290038",
      "code_information": [
        {
          "code": "3603100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER DOME 7MM P20-070-WD00",
      "code_information": [
        {
          "code": "3603132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL LG 2.4X160M P99-100-2416",
      "code_information": [
        {
          "code": "3603134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 4.5MM AR-8945-45C",
      "code_information": [
        {
          "code": "3603164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3603223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL WIDENING 4MM 92141",
      "code_information": [
        {
          "code": "3603263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X82 P65-105-3030-S",
      "code_information": [
        {
          "code": "3603433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2X8X72 P65-105-2008-S",
      "code_information": [
        {
          "code": "3603436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-3.5X8MM BLUE 48230B",
      "code_information": [
        {
          "code": "3603757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2.5X8MM WHITE 48230W",
      "code_information": [
        {
          "code": "3603758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-2X8MM GRAY 48230M",
      "code_information": [
        {
          "code": "3603761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.7 FOOTPRINT 72205888",
      "code_information": [
        {
          "code": "3603793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-PLATE TEMP 705019",
      "code_information": [
        {
          "code": "3603817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-BL NEEDLE AR-7289",
      "code_information": [
        {
          "code": "3603840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-STERNAL AR-7288T",
      "code_information": [
        {
          "code": "3603885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP 388.174",
      "code_information": [
        {
          "code": "3603898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.5X91/4MM STOP DG 317.781",
      "code_information": [
        {
          "code": "3603899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-SCREW T20 57DRVT20",
      "code_information": [
        {
          "code": "3603903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INDUCTIVE HST NR340K9256",
      "code_information": [
        {
          "code": "3603913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUCKLE-INDUCTIVE NR340B9256",
      "code_information": [
        {
          "code": "3603930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QFIX 1.8MM 72290118",
      "code_information": [
        {
          "code": "3603977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FEN JT 2MM PIN MPDP0020",
      "code_information": [
        {
          "code": "3604047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.6 F/4MM MSN10012",
      "code_information": [
        {
          "code": "3604051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X30X100 P65-105-3031-S",
      "code_information": [
        {
          "code": "3604127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM AR-4160-24",
      "code_information": [
        {
          "code": "3604150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.3 F/4.5MM MSN10006",
      "code_information": [
        {
          "code": "3604155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STIM 8225401",
      "code_information": [
        {
          "code": "3604210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-TRUDI PT TPT",
      "code_information": [
        {
          "code": "3604211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-3X200X100 P65-105-3020-S",
      "code_information": [
        {
          "code": "3604269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK RC AR-3650DS",
      "code_information": [
        {
          "code": "3604296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HD SCORPION AR-13999HDN",
      "code_information": [
        {
          "code": "3604298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLV 1.8X400 643518400",
      "code_information": [
        {
          "code": "3604331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-SMTH 1.8X400 641018400",
      "code_information": [
        {
          "code": "3604332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TRC 3X370 AR-9091K-30",
      "code_information": [
        {
          "code": "3604350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 1.7X120 P99-110-1712",
      "code_information": [
        {
          "code": "3604378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-RELINE C 3990002",
      "code_information": [
        {
          "code": "3604439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTO 2.2F/115 CYB-2",
      "code_information": [
        {
          "code": "3604566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 3MM 5820-009-030",
      "code_information": [
        {
          "code": "3604572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-PRECISION 4MM 5820-009-040",
      "code_information": [
        {
          "code": "3604573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MARK OMNI H787137097015",
      "code_information": [
        {
          "code": "3604575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-MICRO KNIFE 28164MC-S",
      "code_information": [
        {
          "code": "3604595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UTERINE 30 KC-RUMI-30",
      "code_information": [
        {
          "code": "3604602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-25",
      "code_information": [
        {
          "code": "3604603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTERINE KC-RUMI-40",
      "code_information": [
        {
          "code": "3604604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 WHITE 48345W",
      "code_information": [
        {
          "code": "3604672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 45 BLUE 48345B",
      "code_information": [
        {
          "code": "3604673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 100 AR-8964R-150",
      "code_information": [
        {
          "code": "3604778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 250 AR-8964R-250",
      "code_information": [
        {
          "code": "3604779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 300 AR-8964R-300",
      "code_information": [
        {
          "code": "3604780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.5X135MM 542020",
      "code_information": [
        {
          "code": "3604831",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO HF 125 AR-3210-0052",
      "code_information": [
        {
          "code": "3604836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BN 3X900 AR-9095-39S",
      "code_information": [
        {
          "code": "3604848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM CN AR-1218-50",
      "code_information": [
        {
          "code": "3604938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1566,
          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED PRASS 8227304",
      "code_information": [
        {
          "code": "3604956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X145MM 542050",
      "code_information": [
        {
          "code": "3604974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER TUBE 22FR 98433",
      "code_information": [
        {
          "code": "3604979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-3H RANCHO 76-10208",
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        {
          "code": "3605033",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3MM P20-915-3000",
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        {
          "code": "3605072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-3.5/SHORT AR-8964-15",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-17\\\"\\\" AR-7237-17LN",
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          "code": "3605098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSSEPTAL FND01902",
      "code_information": [
        {
          "code": "3824363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X14X5MM 607414",
      "code_information": [
        {
          "code": "3900003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X16X6MM 607416",
      "code_information": [
        {
          "code": "3900004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X18X7MM 607418",
      "code_information": [
        {
          "code": "3900005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X20X8MM 607420",
      "code_information": [
        {
          "code": "3900006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X22X9MM 607422",
      "code_information": [
        {
          "code": "3900007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X24X10MM 607424",
      "code_information": [
        {
          "code": "3900008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X26X12MM 607426",
      "code_information": [
        {
          "code": "3900009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X28X14MM 607428",
      "code_information": [
        {
          "code": "3900010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X30X14MM 607430",
      "code_information": [
        {
          "code": "3900011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X32X14MM 607432",
      "code_information": [
        {
          "code": "3900012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X34X14MM 607434",
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        {
          "code": "3900013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X38X14MM 607438",
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        {
          "code": "3900014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X40X14MM 607440",
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        {
          "code": "3900015",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X42X14MM 607442",
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        {
          "code": "3900016",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
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              "standard_charge_dollar": 802.6376,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "3900017",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X48X15MM 607448",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X50X15MM 607450",
      "code_information": [
        {
          "code": "3900020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.6376,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X55X16MM 607455",
      "code_information": [
        {
          "code": "3900021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 328.86,
          "maximum": 1146.6252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 802.6376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4.0X60X16MM 607460",
      "code_information": [
        {
          "code": "3900022",
          "type": "LOCAL"
        },
        {
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        },
        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK PERI 5X8MM 661308",
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        {
          "code": "3900255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OVER 2.0X122MM AO 705137",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEG-LOCK 2.0X18MM 656618",
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        {
          "code": "3900257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          ]
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    {
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        {
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            }
          ]
        }
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    },
    {
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        },
        {
          "code": "0270",
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        }
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            }
          ]
        }
      ],
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    {
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          "type": "LOCAL"
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        {
          "code": "0270",
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        }
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            }
          ]
        }
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    {
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        },
        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
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        }
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            }
          ]
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    {
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        },
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        }
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            }
          ]
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    {
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        },
        {
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            }
          ]
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      ],
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    {
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        },
        {
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        }
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            }
          ]
        }
      ],
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        {
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          ]
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    {
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          ]
        }
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    {
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        },
        {
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        }
      ],
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        },
        {
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        }
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        }
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        {
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        }
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        }
      ],
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        {
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        }
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            }
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        },
        {
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        {
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    {
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        },
        {
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    },
    {
      "description": "PLATE-HAND 3X2H/1.7MM 57-10391",
      "code_information": [
        {
          "code": "3900462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/2.3 57-15391",
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        {
          "code": "3900463",
          "type": "LOCAL"
        },
        {
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        }
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7MM 57-10392",
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        {
          "code": "3900464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7MM 57-10395",
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        {
          "code": "3900465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
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        },
        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
      ],
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    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
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        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/1.7MM 57-10368",
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        },
        {
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        }
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          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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        }
      ],
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        },
        {
          "code": "0270",
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          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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      ],
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        {
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          ]
        }
      ],
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    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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    {
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        },
        {
          "code": "0270",
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        }
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        {
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      ],
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    {
      "description": "PLATE-T 2X10H/2.0X62MM 629771",
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        },
        {
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          ]
        }
      ],
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    },
    {
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        },
        {
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        {
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    {
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        },
        {
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        {
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          ]
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    {
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        },
        {
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    {
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        },
        {
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    },
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        },
        {
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        }
      ],
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        },
        {
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        },
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    {
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        },
        {
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        }
      ],
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    },
    {
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        {
          "code": "3900515",
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        },
        {
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        {
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        {
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        {
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        }
      ],
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        {
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          ]
        }
      ],
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    },
    {
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        {
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      ],
      "standard_charges": [
        {
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          "minimum": 31.1097,
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            }
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC 3-LUMEN PWR INJ SAFET",
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        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH LUMEN 4FR    AK-14402",
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        {
          "code": "1110376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 38.927,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 19G X .75",
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        {
          "code": "1113245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 240.2352,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS          G04153",
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        {
          "code": "1113258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 465.4557,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-FOREIGN BODY   FB-5000",
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        {
          "code": "1115735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 837,
          "minimum": 58.9466,
          "maximum": 607.4109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 425.1876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEONATE TUBE RESV",
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        {
          "code": "1115845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 36.2377,
          "maximum": 911.4479,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATHETER CRICOTHYROTOMY",
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        {
          "code": "1118135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 31.1416,
          "maximum": 1189.4223,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 832.5956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-HANGING CAST LG 1180LPP",
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        {
          "code": "1118520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.6072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "1118720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 116.781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
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        {
          "code": "1118735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 210,
          "minimum": 71.7916,
          "maximum": 636.7345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 106.6779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "#1855G 5-0 ETHILON PC-1",
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        {
          "code": "1118792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 16.7514,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 24.8915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EVAC/DRAIN 1-BTL  62287",
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        {
          "code": "1118801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 188.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED       8CFN",
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        {
          "code": "1118955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 339,
          "minimum": 22.8001,
          "maximum": 246.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 172.2086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
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        {
          "code": "1119001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 41,
          "minimum": 14.0165,
          "maximum": 29.7537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 20.8276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
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        {
          "code": "1119800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 48,
          "minimum": 16.4095,
          "maximum": 2677.6215,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 24.3835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-15      G00012",
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        {
          "code": "1410067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 147.5333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINL 22X20     G03542",
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        {
          "code": "1410472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 256,
          "minimum": 87.5174,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 130.0454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CUSTOM WASTE BAG",
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        {
          "code": "1410792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-INDIGO W/TUBING IAPS2",
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        {
          "code": "1410803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 825.9455,
          "maximum": 2100.3897,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1227.3038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INFUSION MRI          1056",
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        {
          "code": "1410839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 122.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE ADAPTER MRI   1057",
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        {
          "code": "1410840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 153.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.6939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18G 20CM   G01047",
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        {
          "code": "1410918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.2624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18-15      G03954",
      "code_information": [
        {
          "code": "1411193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 74.1847,
          "maximum": 549.4268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.2338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MONOPTY 18X10    121810",
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        {
          "code": "1411612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 63.9515,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JAR-COPLIN PP STAIN     S90130",
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        {
          "code": "1411903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION     CID-20-30",
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        {
          "code": "1412310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 734,
          "minimum": 250.9288,
          "maximum": 631.1735,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 372.8647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE .010-.038   TD01",
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        {
          "code": "1412325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 87.3077,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-STAYFIX SMALL    680-ME",
      "code_information": [
        {
          "code": "1412330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 53.6728,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL IV 6FR   48-152",
      "code_information": [
        {
          "code": "1412380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.2145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL ALL 48-100's",
      "code_information": [
        {
          "code": "1412394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 85.0833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX ALL SZ",
      "code_information": [
        {
          "code": "1413165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 591,
          "minimum": 202.0421,
          "maximum": 428.8887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 300.2221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX ALL SZ",
      "code_information": [
        {
          "code": "1413170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 523,
          "minimum": 120.6737,
          "maximum": 379.5411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 265.6788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN ALL SZS G01xxx",
      "code_information": [
        {
          "code": "1414845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 285.2793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.9883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY ALL SZS",
      "code_information": [
        {
          "code": "1414866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 757.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 216.4037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-10      G01112",
      "code_information": [
        {
          "code": "1414935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "1414990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 77.9452,
          "maximum": 165.4596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.8217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X     C20xxA",
      "code_information": [
        {
          "code": "1414995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-IV SILVERSITE 1X7MM",
      "code_information": [
        {
          "code": "1415449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 2767.7097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-VASCULAR 6MM X 7MM X 5FR",
      "code_information": [
        {
          "code": "1415480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT GASTRO INITIAL SM",
      "code_information": [
        {
          "code": "1415943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 987,
          "minimum": 337.4206,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 501.3861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-150 ML ILLUMENA 900103",
      "code_information": [
        {
          "code": "1416100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 2008.0771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGIOGRAPHY    MCBK001-07",
      "code_information": [
        {
          "code": "1416236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 783,
          "minimum": 267.6802,
          "maximum": 1974.7111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 397.7562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22FR   0250-22",
      "code_information": [
        {
          "code": "1416370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 396.4993,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 796.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENTUIT THRIVE 14F",
      "code_information": [
        {
          "code": "1416371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 713,
          "minimum": 243.7496,
          "maximum": 1623.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 362.1969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-INDIGO             IST3",
      "code_information": [
        {
          "code": "1416377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2920,
          "minimum": 998.2454,
          "maximum": 2119.044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1483.3308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1419101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.4357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX11C",
      "code_information": [
        {
          "code": "1419112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX15C",
      "code_information": [
        {
          "code": "1419113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 20GX15C",
      "code_information": [
        {
          "code": "1419114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX11C",
      "code_information": [
        {
          "code": "1419116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX15C",
      "code_information": [
        {
          "code": "1419118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 601,
          "minimum": 205.4608,
          "maximum": 436.1457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX20C",
      "code_information": [
        {
          "code": "1419119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 601,
          "minimum": 205.4608,
          "maximum": 436.1457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY  20GX11C",
      "code_information": [
        {
          "code": "1419293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 451,
          "minimum": 154.1811,
          "maximum": 556.6561,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 229.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-BIOPSY EVIVA 9G",
      "code_information": [
        {
          "code": "1495152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 39.4831,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-TISSUE ATEC        TF-1",
      "code_information": [
        {
          "code": "1495228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-EVIVA STX   0913-12T",
      "code_information": [
        {
          "code": "1495304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 172.9471,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE MULTICARE  MME-00347",
      "code_information": [
        {
          "code": "1495418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 352.5674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 157.9849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC",
      "code_information": [
        {
          "code": "2395902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 79.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC 50MM",
      "code_information": [
        {
          "code": "2395904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 310.8599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAT-SURGISAFE ABSORBANT FLOOR",
      "code_information": [
        {
          "code": "3000001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 323,
          "minimum": 110.4223,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-FULL RADIUS 5.5MM",
      "code_information": [
        {
          "code": "3000006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 455.159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO               2C4040",
      "code_information": [
        {
          "code": "3000090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CONFIDENCE 2839-99-002",
      "code_information": [
        {
          "code": "3000520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-HEMOSTASES  HC0001",
      "code_information": [
        {
          "code": "3000742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1597,
          "minimum": 545.9582,
          "maximum": 1158.9429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 811.26,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-CLIP MED/LG 20 SMC",
      "code_information": [
        {
          "code": "3000753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 141.8055,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 511.5459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP PK AM0004",
      "code_information": [
        {
          "code": "3000760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 185.0535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.5374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP    AM0005",
      "code_information": [
        {
          "code": "3000762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 11638.0608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.5568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP  DISP   MCM20",
      "code_information": [
        {
          "code": "3000765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 518,
          "minimum": 177.086,
          "maximum": 375.9126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 263.1388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP LARGE MCL20",
      "code_information": [
        {
          "code": "3000766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 553,
          "minimum": 189.0513,
          "maximum": 401.3121,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 280.9185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP SM MCS20",
      "code_information": [
        {
          "code": "3000767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 569,
          "minimum": 194.5211,
          "maximum": 720.1495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 289.0463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-AUTOMATIC 5MM AE05ML",
      "code_information": [
        {
          "code": "3000770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 657.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-ANASTOCLIP LARGE 15CM",
      "code_information": [
        {
          "code": "3000773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSISTANT-SUTURE 5MM     SW100",
      "code_information": [
        {
          "code": "3000865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1311,
          "minimum": 448.1848,
          "maximum": 2858.354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 665.9749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-UROLOGIC DRAIN     9501000",
      "code_information": [
        {
          "code": "3001113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 360.9089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-ANCHOR TISSUE ROBOTIC",
      "code_information": [
        {
          "code": "3001135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 649,
          "minimum": 221.8703,
          "maximum": 470.9793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 329.6855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-ENDOPOUCH 10MM POUCH",
      "code_information": [
        {
          "code": "3001190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-DISPOSA 3MM       DBL-311",
      "code_information": [
        {
          "code": "3001371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 2990.1497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IPRISM IPC05",
      "code_information": [
        {
          "code": "3001669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 363.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAR-TIBIAL LOCKING      141205",
      "code_information": [
        {
          "code": "3002092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1493,
          "minimum": 313.6404,
          "maximum": 1083.4701,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 758.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 1.9X120 390-201",
      "code_information": [
        {
          "code": "3002152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1576,
          "minimum": 538.779,
          "maximum": 1143.7032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 800.5922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CEMENT-COMPACT VACUUM",
      "code_information": [
        {
          "code": "3002214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 99.5419,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.4349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           315.48",
      "code_information": [
        {
          "code": "3002244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 796.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.2      310.65",
      "code_information": [
        {
          "code": "3002246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 207.4253,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1687.5428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MINI DRILL AT2M-1813",
      "code_information": [
        {
          "code": "3002257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 1578.3975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1104.8782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145   03.010.104",
      "code_information": [
        {
          "code": "3002260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1668,
          "minimum": 570.2306,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 847.3273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    351.27",
      "code_information": [
        {
          "code": "3002270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3542,
          "minimum": 497.7095,
          "maximum": 2570.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1799.3006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM      03.010.036",
      "code_information": [
        {
          "code": "3002274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3373,
          "minimum": 1153.1102,
          "maximum": 2447.7861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1713.4503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.060",
      "code_information": [
        {
          "code": "3002289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2190,
          "minimum": 521.0657,
          "maximum": 1589.283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1112.4981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5           310.23",
      "code_information": [
        {
          "code": "3002291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 937,
          "minimum": 320.3274,
          "maximum": 679.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 475.9866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM         310.19",
      "code_information": [
        {
          "code": "3002294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 949,
          "minimum": 324.4298,
          "maximum": 688.6893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 482.0825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MMX150MM  511.417",
      "code_information": [
        {
          "code": "3002302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1642,
          "minimum": 561.3421,
          "maximum": 1191.5994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 834.1196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2 ALL 1806-4200s",
      "code_information": [
        {
          "code": "3002305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1134,
          "minimum": 387.6748,
          "maximum": 822.9438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 576.0607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X180MM 1806-4270S",
      "code_information": [
        {
          "code": "3002306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 156.8202,
          "maximum": 882.4512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 617.7158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR        5091-206",
      "code_information": [
        {
          "code": "3002318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 63.3954,
          "maximum": 204.6474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-STEP DRILL         357.403",
      "code_information": [
        {
          "code": "3002361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3578,
          "minimum": 712.9202,
          "maximum": 2596.5546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1817.5882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.4     310.530",
      "code_information": [
        {
          "code": "3002365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1282,
          "minimum": 438.2708,
          "maximum": 930.3474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 651.2432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           1806-5020S",
      "code_information": [
        {
          "code": "3002379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1219,
          "minimum": 416.7333,
          "maximum": 884.6283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 619.2398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 03.113.024",
      "code_information": [
        {
          "code": "3002394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1440,
          "minimum": 492.2854,
          "maximum": 1045.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 731.5056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 03.113.023",
      "code_information": [
        {
          "code": "3002399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1440,
          "minimum": 492.2854,
          "maximum": 1045.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 731.5056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM 703542",
      "code_information": [
        {
          "code": "3002400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1284,
          "minimum": 438.9545,
          "maximum": 931.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 652.2592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3MM 703541",
      "code_information": [
        {
          "code": "3002402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1335,
          "minimum": 201.8643,
          "maximum": 968.8095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 678.1666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5085-2-032",
      "code_information": [
        {
          "code": "3002403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.4004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM 5085-2-040",
      "code_information": [
        {
          "code": "3002410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.4004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 1.7MM",
      "code_information": [
        {
          "code": "3002760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1755,
          "minimum": 599.9728,
          "maximum": 1273.6035,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 891.5224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO        1806-5000S",
      "code_information": [
        {
          "code": "3002772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1103,
          "minimum": 377.0769,
          "maximum": 1217.859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM     03.010.061",
      "code_information": [
        {
          "code": "3002776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2190,
          "minimum": 748.684,
          "maximum": 1589.283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1112.4981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM    03.010.101S",
      "code_information": [
        {
          "code": "3002777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 1578.3975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1104.8782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.6x",
      "code_information": [
        {
          "code": "3002779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2769,
          "minimum": 946.6238,
          "maximum": 2009.4633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1406.6243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL W/STOP ALL   324.15x",
      "code_information": [
        {
          "code": "3002780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2797,
          "minimum": 870.8526,
          "maximum": 2029.7829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1420.848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.68",
      "code_information": [
        {
          "code": "3002782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2977,
          "minimum": 497.7095,
          "maximum": 2160.4089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1512.2862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 17MM    357.394",
      "code_information": [
        {
          "code": "3002785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4976,
          "minimum": 497.7095,
          "maximum": 3611.0832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2527.7582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM         700347",
      "code_information": [
        {
          "code": "3002791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1337,
          "minimum": 457.0733,
          "maximum": 970.2609,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 679.1826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1MM         702742",
      "code_information": [
        {
          "code": "3002793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1019,
          "minimum": 348.3603,
          "maximum": 739.4883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 517.6418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X110MM     310.35",
      "code_information": [
        {
          "code": "3002794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 921,
          "minimum": 314.8575,
          "maximum": 668.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 467.8588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER MINI       376900",
      "code_information": [
        {
          "code": "3002835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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            }
          ]
        }
      ],
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    },
    {
      "description": "BLADE-SAW 9-9.5MM 5400-031-xxx",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EXT ELECTRODE    E1551-6",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-TURBINATE INF SB2000SA",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SERRATED STND SB4000SS",
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        {
          "code": "3002963",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 60.0588,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MYRINGOTOMY SPEAR TIP",
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        {
          "code": "3003112",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 36.9214,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 54.8629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RAD 40 DEGREE 18-84006HR",
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          "code": "3003122",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 590.4006,
          "maximum": 1253.2839,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RADNOID 18-84008",
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        {
          "code": "3003123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 588.3494,
          "maximum": 1248.9297,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RASP SAW       510037113",
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        {
          "code": "3003127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW MICR 9MM 2296-3-100s",
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        {
          "code": "3003143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG SAW 9X25 ALL 2296s",
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        {
          "code": "3003147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 5.5MMX18MM  KM 3-412",
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          "code": "3003150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW GIGLI ROUND  2808-01",
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        {
          "code": "3003172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 33.366,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HEX COATED 2.75   E1450X",
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        {
          "code": "3003200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 20.5119,
          "maximum": 2242.1952,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-INF TURB 2.0  18-82040HR",
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          "code": "3003227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90Xxx    05.003.1xxS",
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        {
          "code": "3003256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 213.3237,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380HR",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS     519.xxxS",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CELL SAVER HI SP   CSP26x",
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        {
          "code": "3003419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-SMARTMIX CTS    540176501",
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        {
          "code": "3003433",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-INTERNAL AR-1678-CP",
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        {
          "code": "3003471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-UNIV X-ACT 11-2151-9",
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        {
          "code": "3003472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
          "gross_charge": 998,
          "minimum": 89.5321,
          "maximum": 724.2486,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-WHISTLE CLEANING  000101",
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        {
          "code": "3003605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT RND 2296-100-421",
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        {
          "code": "3003756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 39.9982,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL CUTTING 5300-010-901",
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        {
          "code": "3003762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 95.0384,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND          277-10-423",
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        {
          "code": "3003782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 127.8575,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND CUT 2.4MM  5091-225",
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        {
          "code": "3003786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 66.732,
          "maximum": 175.6194,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT 1.6   277-10-xxx",
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        {
          "code": "3003792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 41.0238,
          "maximum": 347.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-WATERMELON      1607-2-35",
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        {
          "code": "3003805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 708.4714,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 316.9858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL   SP-7810",
      "code_information": [
        {
          "code": "3003812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1274,
          "minimum": 435.5358,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 647.1793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 2MM 5820-013-0xx",
      "code_information": [
        {
          "code": "3003829",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 300.294,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 648.7032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND 4.0MM    277-10-240",
      "code_information": [
        {
          "code": "3003855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.0168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 5MM     5820-013-050",
      "code_information": [
        {
          "code": "3003856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING BLUE   FL-601-97B",
      "code_information": [
        {
          "code": "3003905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 158.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT STERILE MAS PLIF",
      "code_information": [
        {
          "code": "3003914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 5832.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1449.2955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ARCH 6.5  80320",
      "code_information": [
        {
          "code": "3004042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.3844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO DBL 5MM PAL-505LL",
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        {
          "code": "3004047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 86.1955,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY PREMATURE",
      "code_information": [
        {
          "code": "3004048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.7384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY NEONATAL",
      "code_information": [
        {
          "code": "3004049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.7384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERPAY INFANT",
      "code_information": [
        {
          "code": "3004051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 411.514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.7384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-308LS",
      "code_information": [
        {
          "code": "3004052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 537.018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 375.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CURVED 100MM 20G 10.0M",
      "code_information": [
        {
          "code": "3004190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.9883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX FEM TFA-022-25",
      "code_information": [
        {
          "code": "3004225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 441.9513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 309.3659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX       TFA02025",
      "code_information": [
        {
          "code": "3004226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 309.3659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 27FR 96370-027",
      "code_information": [
        {
          "code": "3004235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1777,
          "minimum": 607.4939,
          "maximum": 1289.5689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 902.6982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-5FR RAD PIGTAIL 5RPS110-N",
      "code_information": [
        {
          "code": "3004842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 364,
          "minimum": 124.4388,
          "maximum": 1145.0099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.9084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TACKER DELIVERY OMS-TTS",
      "code_information": [
        {
          "code": "3005077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3218,
          "minimum": 870.8526,
          "maximum": 2335.3026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1634.7118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHLOANGIOGRAM   20018-010",
      "code_information": [
        {
          "code": "3005234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 613,
          "minimum": 110.6639,
          "maximum": 444.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 311.3979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 24Fr 5CC 265724",
      "code_information": [
        {
          "code": "3005414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 574.4513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3WAY         73022L",
      "code_information": [
        {
          "code": "3005435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 1478.6699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-PASSER            8591-38",
      "code_information": [
        {
          "code": "3006601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1761.7248,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 34FR-46FR ALL",
      "code_information": [
        {
          "code": "3007230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 442.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 309.8739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 36FR-46FR  TF36460",
      "code_information": [
        {
          "code": "3007235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 442.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 309.8739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP         AA01",
      "code_information": [
        {
          "code": "3007600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-ACU-DISPO      DCFT2",
      "code_information": [
        {
          "code": "3007601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 1595.4509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.0648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP,MULTI-PIN LG 390.004",
      "code_information": [
        {
          "code": "3008494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4727,
          "minimum": 1615.9952,
          "maximum": 3430.3839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2401.2687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-NV DSC & IN-LINE ACTIVATO",
      "code_information": [
        {
          "code": "3008690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 432.0897,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LAPRA-TY ABS SUTURE XC200",
      "code_information": [
        {
          "code": "3008699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 777,
          "minimum": 52.2734,
          "maximum": 563.8689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 394.7082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIPS-HEM-O-LOC         544230",
      "code_information": [
        {
          "code": "3008728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK LG       544240",
      "code_information": [
        {
          "code": "3008730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.6232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK XL       544250",
      "code_information": [
        {
          "code": "3008731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X3/8 XA6062",
      "code_information": [
        {
          "code": "3009659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 871,
          "minimum": 297.7643,
          "maximum": 2382.3324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 442.4593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR ACCU-FLO 82-1504",
      "code_information": [
        {
          "code": "3009774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 387.3329,
          "maximum": 2246.0879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 575.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONSTAVAC-CBC II    225-28-614",
      "code_information": [
        {
          "code": "3009792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1463,
          "minimum": 83.415,
          "maximum": 1061.6991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 743.1894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR BOVIE DISP 301538",
      "code_information": [
        {
          "code": "3009842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 155.708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR HIGH   26176LD/10",
      "code_information": [
        {
          "code": "3009843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 1074.9413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNULATED",
      "code_information": [
        {
          "code": "3009845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1933,
          "minimum": 660.8248,
          "maximum": 1402.7781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNUL 3.8MM",
      "code_information": [
        {
          "code": "3009850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 50.049,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 913.874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-SILICONE RETRACTOR",
      "code_information": [
        {
          "code": "3009851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 158.4885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.7191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-DISPOSABLE ACTIVE DAC",
      "code_information": [
        {
          "code": "3009853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 1787.3054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.7771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-8 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 187.2306,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.0614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 206.8245,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.7771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 10191.6447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.0009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 252.5436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.7805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-30 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 188.9723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 428,
          "minimum": 146.3182,
          "maximum": 310.5996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 217.4197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MERCEDES     PAL-506LL",
      "code_information": [
        {
          "code": "3010053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 2360.0884,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS ALL SZS   681xx",
      "code_information": [
        {
          "code": "3010076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 551,
          "minimum": 188.3675,
          "maximum": 2007.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 279.9025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT ALL SZ",
      "code_information": [
        {
          "code": "3010079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 1508.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 194.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL 1X4  2111-04-077",
      "code_information": [
        {
          "code": "3010088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2712,
          "minimum": 927.1375,
          "maximum": 3166.9895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1377.6689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL ALL  2111-08-07x",
      "code_information": [
        {
          "code": "3010090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5695,
          "minimum": 265.2597,
          "maximum": 4132.8615,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2893.003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X20 657320",
      "code_information": [
        {
          "code": "3010104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 691.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X40 657340",
      "code_information": [
        {
          "code": "3010107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 691.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DUBIN              8390",
      "code_information": [
        {
          "code": "3010215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 494.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION         BID30",
      "code_information": [
        {
          "code": "3010259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 890,
          "minimum": 265.8158,
          "maximum": 645.873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 452.1111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE TISSUE REMOVAL",
      "code_information": [
        {
          "code": "3010310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1901.3059,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LAPARSCOP PLUME FILTER",
      "code_information": [
        {
          "code": "3010330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 198,
          "minimum": 67.6892,
          "maximum": 5379.1553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VAGINAL POSITIONING",
      "code_information": [
        {
          "code": "3010598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2367,
          "minimum": 809.1941,
          "maximum": 1717.7319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1202.4123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-BLUNT TIP 5 PK BTD05",
      "code_information": [
        {
          "code": "3010867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1 5901-1126",
      "code_information": [
        {
          "code": "3011002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 207.4253,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.6796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHAN W/TROCAR ALL SIZES",
      "code_information": [
        {
          "code": "3011730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 199,
          "minimum": 43.3758,
          "maximum": 144.4143,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 101.09,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT HUBLESS ALL SZS",
      "code_information": [
        {
          "code": "3011780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.6232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-MINI CHEST 500     16400",
      "code_information": [
        {
          "code": "3011787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1139,
          "minimum": 389.3841,
          "maximum": 826.5723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 578.6006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FECAL MANAGEMENT 418000",
      "code_information": [
        {
          "code": "3011910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1469,
          "minimum": 36.1465,
          "maximum": 1066.0533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 746.2373,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FECAL MANAGEMENT 411108",
      "code_information": [
        {
          "code": "3011911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 120.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-HIP W/POUCHES DYNJP8201",
      "code_information": [
        {
          "code": "3011920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 217,
          "minimum": 74.1847,
          "maximum": 157.4769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.2338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BEACH CHAIR SHOULDER",
      "code_information": [
        {
          "code": "3011922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 257,
          "minimum": 87.8593,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.5534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BARIATRIC      DYNJP3105",
      "code_information": [
        {
          "code": "3011926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 77.9452,
          "maximum": 271.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.8217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-DOUBLE 44X66     ORS 320",
      "code_information": [
        {
          "code": "3011927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 247.8991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 12MM CD004",
      "code_information": [
        {
          "code": "3011949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 32.2538,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE 3M SHORT   6661EZ",
      "code_information": [
        {
          "code": "3011953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 148.4787,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-ISO IOBAN HIP       6617",
      "code_information": [
        {
          "code": "3011959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 200.196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 135.6333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INTESTINAL 18X18.5 ISO1003",
      "code_information": [
        {
          "code": "3011960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 360,
          "minimum": 123.0713,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 182.8764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 10MM CD001",
      "code_information": [
        {
          "code": "3011961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 44.488,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI     326088-0000-000",
      "code_information": [
        {
          "code": "3011985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 155.1519,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI FULL         306070",
      "code_information": [
        {
          "code": "3011987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 279,
          "minimum": 95.3803,
          "maximum": 328.6551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER           ORS-400",
      "code_information": [
        {
          "code": "3011995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 591,
          "minimum": 33.366,
          "maximum": 428.8887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 300.2221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERI IRRIGATION    1016",
      "code_information": [
        {
          "code": "3012018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 68.9564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE HAND   DYNJP8005",
      "code_information": [
        {
          "code": "3012025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 89.9868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.9908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR GLASSCOCK  S-1000",
      "code_information": [
        {
          "code": "3012051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 266.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 157.9849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GENTLE CARE SURG 12-1",
      "code_information": [
        {
          "code": "3012060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 480,
          "minimum": 164.0951,
          "maximum": 348.336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 243.8352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-TOPIFOAM      5710-30",
      "code_information": [
        {
          "code": "3012080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 57.2783,
          "maximum": 216.9843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED ASNIS III",
      "code_information": [
        {
          "code": "3012111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1063.8193,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.5MM  702450",
      "code_information": [
        {
          "code": "3012114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 673.4371,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-HEX 1.1X67       15-1723",
      "code_information": [
        {
          "code": "3012115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1211,
          "minimum": 413.9983,
          "maximum": 878.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.1759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3012118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 796.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST ASNIS III 6.5MM",
      "code_information": [
        {
          "code": "3012151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN 4.0MM W/AO",
      "code_information": [
        {
          "code": "3012152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5392,
          "minimum": 813.0182,
          "maximum": 3912.9744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2739.0821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SHAFT-AO 2.6MMX122MM",
      "code_information": [
        {
          "code": "3012186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 742.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           310.48",
      "code_information": [
        {
          "code": "3012201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1176,
          "minimum": 402.0331,
          "maximum": 853.4232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 597.3962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1806-5010S",
      "code_information": [
        {
          "code": "3012206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1103,
          "minimum": 377.0769,
          "maximum": 800.4471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 03.6MMX122MM",
      "code_information": [
        {
          "code": "3012207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1378,
          "minimum": 471.0898,
          "maximum": 1000.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 700.0102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 13.0MM CANNULATED",
      "code_information": [
        {
          "code": "3012314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4464,
          "minimum": 540.5292,
          "maximum": 3239.5248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2267.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         MS-DCR20",
      "code_information": [
        {
          "code": "3012321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 959.2725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 LG 120MM",
      "code_information": [
        {
          "code": "3012325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1725,
          "minimum": 589.7169,
          "maximum": 1251.8325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 876.2827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 315.28",
      "code_information": [
        {
          "code": "3012330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1374,
          "minimum": 469.7223,
          "maximum": 997.1118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 697.9783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X40   2274-12-000",
      "code_information": [
        {
          "code": "3012344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1940,
          "minimum": 586.6855,
          "maximum": 1407.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 985.5006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5          MS-DC35",
      "code_information": [
        {
          "code": "3012346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1055,
          "minimum": 360.6674,
          "maximum": 765.6135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.9294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.201",
      "code_information": [
        {
          "code": "3012355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 912,
          "minimum": 311.7808,
          "maximum": 661.8384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 463.2869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL               310.28",
      "code_information": [
        {
          "code": "3012356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 784.6571,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 493.7663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.431",
      "code_information": [
        {
          "code": "3012357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1411,
          "minimum": 482.3713,
          "maximum": 1023.9627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 716.7739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL            32-486265",
      "code_information": [
        {
          "code": "3012365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 769,
          "minimum": 262.8941,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 390.6443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL         5820-107-530",
      "code_information": [
        {
          "code": "3012374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 1340.201,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           AT2M-L1813",
      "code_information": [
        {
          "code": "3012378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2410,
          "minimum": 823.8943,
          "maximum": 1748.937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1224.2559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED   310.634",
      "code_information": [
        {
          "code": "3012380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1357.8573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 5.0MM",
      "code_information": [
        {
          "code": "3012381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1357.8573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM 60-19340",
      "code_information": [
        {
          "code": "3012401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1102,
          "minimum": 376.7351,
          "maximum": 799.7214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 559.805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHRT 3.2 03.010.103S",
      "code_information": [
        {
          "code": "3012406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1666,
          "minimum": 569.5469,
          "maximum": 1209.0162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 846.3113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL 5MM     DBL-511",
      "code_information": [
        {
          "code": "3012461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL LOOP      B0512",
      "code_information": [
        {
          "code": "3012465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 51.1612,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 188.9723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X2.75 E1455",
      "code_information": [
        {
          "code": "3012472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X4  E1455-4",
      "code_information": [
        {
          "code": "3012473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 762.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-208",
      "code_information": [
        {
          "code": "3012474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1372,
          "minimum": 469.0386,
          "maximum": 995.6604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.9623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EZ CLEAN CAUTERY TIP",
      "code_information": [
        {
          "code": "3012505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 43.3758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.4315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE MOD     0014AM",
      "code_information": [
        {
          "code": "3012507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.6232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BOVIE RED      E7507",
      "code_information": [
        {
          "code": "3012513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 231.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK  E2773-45",
      "code_information": [
        {
          "code": "3012520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 61.7271,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 211.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MRI CONDITIONAL DISP",
      "code_information": [
        {
          "code": "3012521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 1396.9232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LIGASURE      LS1037",
      "code_information": [
        {
          "code": "3012535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2512,
          "minimum": 858.7645,
          "maximum": 1822.9584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1276.0709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 2CHAN 8227410",
      "code_information": [
        {
          "code": "3012585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1545,
          "minimum": 528.1812,
          "maximum": 1121.2065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 784.8445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-RADIUS LOOP    R1010",
      "code_information": [
        {
          "code": "3012596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 41.7075,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 188.9723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 6.5\\\" 0014M",
      "code_information": [
        {
          "code": "3012611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 54.4275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.0992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-TEFLON 6 1/2 BLADE",
      "code_information": [
        {
          "code": "3012613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.6072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDCAP-ROUND X-CORE    5960200",
      "code_information": [
        {
          "code": "3012635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4702,
          "minimum": 1037.1265,
          "maximum": 3412.2414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2388.569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3012680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2877,
          "minimum": 983.5452,
          "maximum": 2974.5789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1461.4872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVACUATOR-UROVAC       730-125",
      "code_information": [
        {
          "code": "3012699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 100.098,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVAC-SAF-T-VAC         ST9000S",
      "code_information": [
        {
          "code": "3012723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 667.8761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.4382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-GLUE             540133500",
      "code_information": [
        {
          "code": "3012805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 199.0838,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXCISOR-BIOPSY CONE",
      "code_information": [
        {
          "code": "3012815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-DIALYSIS CATH  415612",
      "code_information": [
        {
          "code": "3012854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1265,
          "minimum": 432.459,
          "maximum": 918.0105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.6073,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTRACTOR-TRIGEN DISP 71631320",
      "code_information": [
        {
          "code": "3012895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.4349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBE-VIPERSLIDE VPR-SLD2",
      "code_information": [
        {
          "code": "3012925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.6796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 1X6        007976",
      "code_information": [
        {
          "code": "3012991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 1153.3514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 493.2583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 4\\\"X4\\\"       007836",
      "code_information": [
        {
          "code": "3012993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2074,
          "minimum": 709.0277,
          "maximum": 7269.3392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1053.5713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 200M",
      "code_information": [
        {
          "code": "3013060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2420,
          "minimum": 827.313,
          "maximum": 1756.194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1229.3358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 365M",
      "code_information": [
        {
          "code": "3013061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2010,
          "minimum": 687.1484,
          "maximum": 1473.1089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1021.0599,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 550M",
      "code_information": [
        {
          "code": "3013062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2649,
          "minimum": 905.6,
          "maximum": 2081.4823,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1345.6655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 1000M",
      "code_information": [
        {
          "code": "3013063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3743,
          "minimum": 1066.0437,
          "maximum": 2716.2951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1901.4066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-COUDE HEYMAN   021300",
      "code_information": [
        {
          "code": "3013087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1917,
          "minimum": 655.3549,
          "maximum": 1391.1669,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 973.8168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-HEYMAN         021100",
      "code_information": [
        {
          "code": "3013090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1718,
          "minimum": 365.3577,
          "maximum": 1246.7526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 872.7268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPER-          AR-7237-7",
      "code_information": [
        {
          "code": "3013107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 1783.4127,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 3  AR-7227-01",
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        {
          "code": "3013134",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 112.4735,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 4  AR-7230-01",
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        {
          "code": "3013135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 43.3758,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-HEPA BACTERIA 00182",
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        {
          "code": "3013160",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PED OXYKID W/7' TUBING",
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        {
          "code": "3013161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 75.6296,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-INSUFFLATION BULB",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 46.4936,
          "maximum": 131.7957,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP     1599-05",
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        {
          "code": "3013203",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 81.022,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 120.3936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-PIRANHA 3FR     505-160",
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        {
          "code": "3013317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2055,
          "minimum": 69.5125,
          "maximum": 1491.3135,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1043.9194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW      000300s",
      "code_information": [
        {
          "code": "3013320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 90.7125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.4987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GEL-PROLARYN          8602M0K5",
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        {
          "code": "3013462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4034,
          "minimum": 1379.0828,
          "maximum": 52874.5441,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2049.2317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 1.4X150MM",
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        {
          "code": "3014234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 509.514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 6.5 DRILL",
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        {
          "code": "3014235",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-AR-8737-01",
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        {
          "code": "3014239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 113.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM 10X7.5CM",
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        {
          "code": "3014272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 3372.7465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.2305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-DBX MIX 2.5CC     058025",
      "code_information": [
        {
          "code": "3014900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2432,
          "minimum": 831.4153,
          "maximum": 2273.3368,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1235.4317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-HELI-FX            SG-64",
      "code_information": [
        {
          "code": "3016110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 107.8834,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-WIRE .035      WS-0906ST",
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        {
          "code": "3016121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2MM           292.65",
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        {
          "code": "3016129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 188.7094,
          "maximum": 400.5864,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "WIRE-K SMOOTH TIP AGK16100",
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        {
          "code": "3016134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 106.6618,
          "maximum": 606.7051,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-3.2       03.010.115",
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        {
          "code": "3016135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1091,
          "minimum": 372.9746,
          "maximum": 791.7387,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K W/OLIVE STOP",
      "code_information": [
        {
          "code": "3016136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 263.5914,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-SUT GABBY-FRATER SUT 013",
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        {
          "code": "3016153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 695.125,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP AR894301",
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        {
          "code": "3016164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 102.2176,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-HALTER DISP 08143101",
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        {
          "code": "3016272",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 40.3401,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ADHESIVE 4\\\" WHITE",
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        {
          "code": "3016326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 38.2889,
          "maximum": 58022.9179,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 56.8949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1963",
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        {
          "code": "3016347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1292,
          "minimum": 114.5566,
          "maximum": 937.6044,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 656.3231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOVAC-400ML LG   2550-004-10",
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        {
          "code": "3016381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 1215.6346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.6459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-HYDRODEB     1914001",
      "code_information": [
        {
          "code": "3016387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2186,
          "minimum": 747.3166,
          "maximum": 1586.3802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1110.4661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM SNGL PK 33508G",
      "code_information": [
        {
          "code": "3016420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 2308.9272,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 98.5501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM DOUBLE  3384-4",
      "code_information": [
        {
          "code": "3016425",
          "type": "LOCAL"
        },
        {
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        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 2X4 2082",
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        {
          "code": "3016450",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 331.9508,
          "maximum": 704.6547,
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 4X4 2083",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 1754.4955,
          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-J CAUTERY     60-5272-232",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 93.671,
          "maximum": 2666.4995,
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-ULTRASLING III XLG",
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          "code": "3017486",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 147.6856,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUTTLE-ACCU PASS SUTURE 70DEG",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-EVERGRIP LF  EVERGRIP61",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FDG",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGL",
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        {
          "code": "3019813",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGD",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-PEELAWAY 16F",
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          "code": "3019878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT 9FR 3 1/2 PI93",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 130.2505,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2MM 500373",
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        {
          "code": "3020202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 242.3822,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPER DISTRACTOR FF904SB",
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        {
          "code": "3020203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 362.3768,
          "maximum": 769.242,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 17L 96550",
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        {
          "code": "3020800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 176.0604,
          "maximum": 2737.6803,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-I RING PUPIL 587000",
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        {
          "code": "3020804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 427.6729,
          "maximum": 907.8507,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 635.4955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL VISULIZATION",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
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          "minimum": 356.9069,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUG 03.804.522S",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 56.7222,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SCOPE WARMER TM500",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENTI SCAN IV DISP 177-092",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "KIT-ACCESSORY 700     72401850",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1870.6845,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COAG  CSP208",
      "code_information": [
        {
          "code": "3020850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 76.5777,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DILATOR NVM5       2029950",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-19",
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        {
          "code": "3020920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 465.6199,
          "maximum": 1248.4445,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 691.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-21",
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        {
          "code": "3020922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 1629.1965,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1140.4375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC     96530-017",
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        {
          "code": "3020928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 2227.1805,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 597.9042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IV MAXCESS         3240060",
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        {
          "code": "3020969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8227,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4179.2337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX PT STARTER  50-0071",
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        {
          "code": "3021029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 782.5287,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1162.7891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHUNT NONINVASIVE  9733605",
      "code_information": [
        {
          "code": "3021032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3599,
          "minimum": 895.321,
          "maximum": 2611.7943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1828.256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 4ML 1501262",
      "code_information": [
        {
          "code": "3021034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1610,
          "minimum": 264.7036,
          "maximum": 1168.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 817.8639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH&BOOT 3550-80",
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        {
          "code": "3021046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 476,
          "minimum": 162.7277,
          "maximum": 1362.445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 241.8032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERITONEAL DIALYSIS 278006",
      "code_information": [
        {
          "code": "3021065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1150,
          "minimum": 96.2053,
          "maximum": 834.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 584.1885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHOULDER CANNULA 5CM  9718",
      "code_information": [
        {
          "code": "3021080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 974.8433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.8823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-URO MAX HI PRESURE 225-136",
      "code_information": [
        {
          "code": "3021090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1753,
          "minimum": 599.2891,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 890.5065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXTRACTION GTG14",
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        {
          "code": "3021113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4570,
          "minimum": 1562.3224,
          "maximum": 3316.449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2321.5143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X12MM 663812",
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        {
          "code": "3021130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 951,
          "minimum": 67.2881,
          "maximum": 690.1407,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 483.0985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE,SLIT 2.4MM 45 DEGREE",
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        {
          "code": "3021161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 1114.4244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 133.6014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-GRAFT ACL 10MM    232110",
      "code_information": [
        {
          "code": "3021173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2004,
          "minimum": 271.3768,
          "maximum": 1454.3028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1018.012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT CLEAR CUT 2.4",
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        {
          "code": "3021199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 58.9466,
          "maximum": 354.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 247.8991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDE PORT 1.1    78-2010",
      "code_information": [
        {
          "code": "3021203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 937.5846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-TUIP             880-217",
      "code_information": [
        {
          "code": "3021220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 749,
          "minimum": 256.0568,
          "maximum": 667.8761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 380.4845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE ALL AR-4000Ss",
      "code_information": [
        {
          "code": "3021225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE         AR-4068's",
      "code_information": [
        {
          "code": "3021227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 4811.9333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 742.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDEPORT SAFETY 1.0MM",
      "code_information": [
        {
          "code": "3021241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 110.7642,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINER-SZ25/36MM RL 12-105995",
      "code_information": [
        {
          "code": "3021635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4400,
          "minimum": 1504.2054,
          "maximum": 8241.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2235.156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-IMPACT         LF4318",
      "code_information": [
        {
          "code": "3021733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2708,
          "minimum": 145.1421,
          "maximum": 1965.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1375.6369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-DRAINAGE LOCKABLE 50-7245",
      "code_information": [
        {
          "code": "3021737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.5854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 26FR      880-214",
      "code_information": [
        {
          "code": "3021821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 134.0201,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 352.5451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-DISPOSA ALL",
      "code_information": [
        {
          "code": "3021826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-ELECTRODE 24FR   WA22037C",
      "code_information": [
        {
          "code": "3021880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1483,
          "minimum": 326.4307,
          "maximum": 1076.2131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 753.3492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WIRE SNARE 8-14515",
      "code_information": [
        {
          "code": "3021881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 1048.8046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 298.1901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-MS SSEP NEEDLE  8050315",
      "code_information": [
        {
          "code": "3022945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5246,
          "minimum": 1793.4231,
          "maximum": 3807.0222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2664.9155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE EMG 8050015",
      "code_information": [
        {
          "code": "3022950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE MEP/EMG",
      "code_information": [
        {
          "code": "3022955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 4022.8274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2579.0652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SINGLE PORT PAL 240LS",
      "code_information": [
        {
          "code": "3023177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 4022.8274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 404.36,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY STEALTH  9733068",
      "code_information": [
        {
          "code": "3027284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4784,
          "minimum": 117.8932,
          "maximum": 3471.7488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2430.2242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY TRU CUT 2N2700s",
      "code_information": [
        {
          "code": "3027285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 153.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.6939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY CUT      4418-16",
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        {
          "code": "3027295",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DEFLUX 23GX3.7FX350mm",
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        {
          "code": "3027296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 254.3475,
          "maximum": 539.9208,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DISP INSUF      S100000",
      "code_information": [
        {
          "code": "3027310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 45.0441,
          "maximum": 349.7874,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ELECTRODE COATD E1465-6",
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        {
          "code": "3027313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 27.6911,
          "maximum": 399.8359,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ENDOPATH INSUFF   PN120",
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        {
          "code": "3027315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 245.8008,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "NEEDLE-EPIDURAL       105-1314",
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        {
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-20      G00013",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 54.3565,
          "maximum": 230.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FORAMEN 20G      041829",
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        {
          "code": "3027344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 301.1655,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-6 DJ6011X",
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        {
          "code": "3027346",
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        },
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          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 99.8245,
          "maximum": 216.879,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR        1650050",
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        {
          "code": "3027347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 283.023,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSULATED EDGE   E1465B",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 719.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TR-CRON 2-0 STR W/10 SW",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 149.3949,
          "maximum": 348.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 221.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR W/SHEATH",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 214.0074,
          "maximum": 454.2882,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OPUS SPEEDSTITCH",
      "code_information": [
        {
          "code": "3027425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 135.7203,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OCTRODE 6\\\"         1116",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 244.7752,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODESSECTION   N103A",
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        {
          "code": "3027433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 235.8868,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 350.5131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION      AR-13991N",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SIDEKICK 21GA 14.6\\\"",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 207.4253,
          "maximum": 575.4801,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODISSECTION   E1xxx",
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        {
          "code": "3027520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "maximum": 576.9315,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-W/BASEPLATE BSDN-18-7.0",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 5MM  VS101005",
      "code_information": [
        {
          "code": "3027591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VERSASTEP 14GA VS150000",
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        {
          "code": "3027593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TROCAR 12MM VS101000s",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 888.2568,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SYSTEM-WILSON PENILE IMPLANT",
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        {
          "code": "3029175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 856.0296,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1272.007,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FENWAL TRANSFER 4R2014",
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        {
          "code": "3029199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 34.8702,
          "maximum": 373.1431,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-EXTREMITY      DYNJ31779F",
      "code_information": [
        {
          "code": "3029200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 75.6296,
          "maximum": 486.9447,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 340.8613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAGNETIC DRAPE    31140562",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 46.4936,
          "maximum": 1966.3696,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY ELITE VIAL     LC3001",
      "code_information": [
        {
          "code": "3029202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3536,
          "minimum": 1208.8341,
          "maximum": 2566.0752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1796.2526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SENSA TRAC M8275057/10",
      "code_information": [
        {
          "code": "3029214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 92.6454,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-PERFUSION CUSTOM  CK0226R",
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        {
          "code": "3029252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 145.1421,
          "maximum": 2898.4458,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SHOULDER ARTHROSCOP 29367",
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        {
          "code": "3029266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 89.2267,
          "maximum": 189.4077,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SINUS KENNEDY      400422",
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        {
          "code": "3029267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 109.7386,
          "maximum": 656.198,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-TOTAL JOINT    DYNJ31778A",
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        {
          "code": "3029268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 99.5419,
          "maximum": 856.326,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM     440400",
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        {
          "code": "3029278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAK-CONFIDENCE PLUS",
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        {
          "code": "3029292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HAND DYNJ52365",
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        {
          "code": "3029301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 217.4261,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 323.0816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VITRECTOMY CENTURION",
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        {
          "code": "3029308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 796.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH  82-151x",
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        {
          "code": "3029345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1307,
          "minimum": 446.8174,
          "maximum": 948.4899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.9429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SMART STITCH PERFECT",
      "code_information": [
        {
          "code": "3029347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 917,
          "minimum": 265.8158,
          "maximum": 665.4669,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 465.8268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE           032401",
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        {
          "code": "3029348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 396.4993,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-HEMA KNITTED   HGK75/75P",
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        {
          "code": "3029426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
          "gross_charge": 1254,
          "minimum": 428.6985,
          "maximum": 7405.5837,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 637.0195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-ACTIVA 2.5 INTELLIDOSE",
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        {
          "code": "3029528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 74.6745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-DISPOSABLE  26-1221",
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        {
          "code": "3029529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 2058.1261,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1360.3972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORIENTATION 2307-71-000",
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        {
          "code": "3029762",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 721.3458,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 504.9421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-NAVIGATION 6007-003-150",
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        {
          "code": "3029767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 150.7031,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 474.9706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ARM ELEVATION 79-90500",
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        {
          "code": "3029771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 520.5096,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 137.6653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KNEE PROCEDURE TRACK 10712",
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        {
          "code": "3029811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 180.7325,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 691.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-DEMAYO LEG 110550",
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        {
          "code": "3029813",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 533.856,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 165.0967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BREAKAWAY GUIDE 2.5MM",
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        {
          "code": "3029840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 603.9246,
          "maximum": 1890.4485,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1323.3139,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144110",
      "code_information": [
        {
          "code": "3029841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1086,
          "minimum": 371.2652,
          "maximum": 788.1102,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 551.6771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DHS GUIDE          900.723",
      "code_information": [
        {
          "code": "3029855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 224.9471,
          "maximum": 551.6512,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 334.2574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-POSITIONING EZ CLIP 2MM",
      "code_information": [
        {
          "code": "3029858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1123,
          "minimum": 383.9142,
          "maximum": 1046.0241,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 570.4728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-FLUTED HEADLESS 7650-2038A",
      "code_information": [
        {
          "code": "3029885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1881,
          "minimum": 616.7149,
          "maximum": 1365.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 955.5292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE              357.399",
      "code_information": [
        {
          "code": "3029929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1109,
          "minimum": 379.1281,
          "maximum": 3924.9538,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PINS-GUIDE 7.3         900.726",
      "code_information": [
        {
          "code": "3030050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 943,
          "minimum": 207.4253,
          "maximum": 684.3351,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 479.0346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1\\\"",
      "code_information": [
        {
          "code": "3033301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 16.4095,
          "maximum": 34.8336,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 24.3835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 16FR 10ML",
      "code_information": [
        {
          "code": "3033303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F SCREWS 45-80040",
      "code_information": [
        {
          "code": "3033883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1582.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 742.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-LARGE SOFT       PCP40",
      "code_information": [
        {
          "code": "3033952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POINTER-TRACER         9733423",
      "code_information": [
        {
          "code": "3034140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3396,
          "minimum": 175.7276,
          "maximum": 2464.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1725.134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-BIOPSY             AUR-BP",
      "code_information": [
        {
          "code": "3034190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 316,
          "minimum": 108.0293,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-GEL HAND            C8XX2",
      "code_information": [
        {
          "code": "3034194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2006.0525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOCATCH-II W/POUCH ALL 173's",
      "code_information": [
        {
          "code": "3034302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2140,
          "minimum": 497.7095,
          "maximum": 1552.998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1087.0986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD ENTERAL 7FR 350CM",
      "code_information": [
        {
          "code": "3034510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 796.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NEUROVISION M5   2012021",
      "code_information": [
        {
          "code": "3034522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 592.2465,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 2.3MM 6.9FR 300CM",
      "code_information": [
        {
          "code": "3034891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 8367.0806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-WOUND GELPOINT CNGL2",
      "code_information": [
        {
          "code": "3038330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 19421.7925,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2149.3057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-PAIN ONQ 400ML    PM028-A",
      "code_information": [
        {
          "code": "3038635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1884,
          "minimum": 644.0734,
          "maximum": 3289.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 957.0532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-KNOT 2-0 FIBERWIRE",
      "code_information": [
        {
          "code": "3038667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 99.5419,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 662.9269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-DEKNATEL 4.4      MDP-44",
      "code_information": [
        {
          "code": "3038930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 398,
          "minimum": 136.0622,
          "maximum": 525.5145,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 202.18,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GREEN    ECR45G",
      "code_information": [
        {
          "code": "3039881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1406,
          "minimum": 207.4253,
          "maximum": 1020.3342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 714.2339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO LINEAR       TR35B",
      "code_information": [
        {
          "code": "3039888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 838,
          "minimum": 47.2685,
          "maximum": 608.1366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 425.6956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-TUBING         RF10210",
      "code_information": [
        {
          "code": "3039889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 80.0784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W564",
      "code_information": [
        {
          "code": "3039894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 104.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.1506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W332",
      "code_information": [
        {
          "code": "3039896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 239.6791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.1506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN        XR30G",
      "code_information": [
        {
          "code": "3039899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 431,
          "minimum": 147.3438,
          "maximum": 312.7767,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.9437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH       170056",
      "code_information": [
        {
          "code": "3039902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 676.2176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 437.8874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-VASCULAR/THIN     TR45W",
      "code_information": [
        {
          "code": "3039909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 239.6791,
          "maximum": 882.4512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 617.7158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM              XR30B",
      "code_information": [
        {
          "code": "3039911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 431,
          "minimum": 147.3438,
          "maximum": 676.2176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.9437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STANDARD BLUE     6R45B",
      "code_information": [
        {
          "code": "3039912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 415.7077,
          "maximum": 944.8139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 617.7158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40B",
      "code_information": [
        {
          "code": "3039913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1699,
          "minimum": 277.4939,
          "maximum": 1232.9643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 863.075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD- STAPLE TCR-55",
      "code_information": [
        {
          "code": "3039914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 499,
          "minimum": 170.5906,
          "maximum": 456.002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 253.487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-LINEAR CUTTER    TCR-75",
      "code_information": [
        {
          "code": "3039916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 820,
          "minimum": 280.3292,
          "maximum": 944.8139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 416.5518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40G",
      "code_information": [
        {
          "code": "3039917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1699,
          "minimum": 580.8284,
          "maximum": 1232.9643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 863.075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER    TCT75",
      "code_information": [
        {
          "code": "3039918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1465,
          "minimum": 285.8354,
          "maximum": 1063.1505,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 744.2053,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO GIA 30/3.5  030452",
      "code_information": [
        {
          "code": "3039932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2061,
          "minimum": 704.5835,
          "maximum": 1495.6677,
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            {
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-CARIOTOMY        205",
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        {
          "code": "3039975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 158.9672,
          "maximum": 6833.3568,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-DISP FILTRA 04259",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 199.9909,
          "maximum": 7440.618,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-OMMAYA    NL850-121x",
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        {
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          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 170.1666,
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-C-SECTION DISP G6314",
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        {
          "code": "3040500",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEXOR TENDON",
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        {
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          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 600.588,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-LONESTAR        3304",
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        {
          "code": "3040511",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
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          "minimum": 369.214,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "RETRACTOR-ORTHO ALEXIS   HR004",
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        {
          "code": "3040513",
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        {
          "code": "0270",
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE        013593",
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        {
          "code": "3040518",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
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          "minimum": 190.7606,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-SURGICAL RING   3715",
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        {
          "code": "3040521",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 415.4067,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-LOOPED 3 PRONG  5030",
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        {
          "code": "3040525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 255.3731,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND LG       C8303",
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        {
          "code": "3040527",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 224.6052,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND MEDIUM   C8302",
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        {
          "code": "3040530",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 147.0019,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XL       C8304",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "minimum": 239.123,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND SMALL    C8301",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XSMALL   C8312",
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        {
          "code": "3040534",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
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          "minimum": 147.0019,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-MALYUGIN ALL SZS MAL-000x",
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          "code": "0270",
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.8 CANN DRI",
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          "code": "0270",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "SABRE-2.0X7          AR-7200S",
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        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "SEALER-AQUAMANTYS 2.3 BIPOLAR",
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          "code": "0270",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS MALLEABLE BI",
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION ANSPACH 111613",
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        {
          "code": "0270",
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      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "CANNULA-TRI PORT III PAL 303LS",
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    {
      "description": "PIN-BONE 4.0X170 144170",
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        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CELLEBRITY CYTOLOGY",
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        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 79.9964,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATIR SM DISP 13MM",
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        {
          "code": "3055843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 67.3474,
          "maximum": 833.5939,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 100.074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 2ML 1506078",
      "code_information": [
        {
          "code": "3055845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 512.4554,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL ALL SZS 456.30Xs",
      "code_information": [
        {
          "code": "3055898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3677,
          "minimum": 1233.9859,
          "maximum": 2668.3989,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1867.8792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MISTY NEB W/FILTER",
      "code_information": [
        {
          "code": "3058511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 607.2612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-HELIOCOIDAL RASP 3.2MM",
      "code_information": [
        {
          "code": "3058512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1092,
          "minimum": 373.3164,
          "maximum": 995.9751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.7251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONE MILL DISP",
      "code_information": [
        {
          "code": "3058513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1791,
          "minimum": 262.4792,
          "maximum": 1299.7287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 909.8101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-CORE IRRIGATION",
      "code_information": [
        {
          "code": "3058514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 472,
          "minimum": 161.3602,
          "maximum": 605.5929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 239.7713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 2.3MM",
      "code_information": [
        {
          "code": "3058515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1089,
          "minimum": 372.2908,
          "maximum": 790.2873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 553.2011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-SOFT TOUCH RND FLUTED ALL",
      "code_information": [
        {
          "code": "3058516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND ALL SIZES",
      "code_information": [
        {
          "code": "3058517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 436.5614,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 648.7032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND COURSE ALL",
      "code_information": [
        {
          "code": "3058518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 3.0MM",
      "code_information": [
        {
          "code": "3058521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1089,
          "minimum": 372.2908,
          "maximum": 790.2873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 553.2011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CUTTING DIAMOND 25.4X0.8",
      "code_information": [
        {
          "code": "3058522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1042,
          "minimum": 356.2232,
          "maximum": 862.5111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 529.3256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 310.23S",
      "code_information": [
        {
          "code": "3058526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1551,
          "minimum": 530.2324,
          "maximum": 1125.5607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 787.8925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 02.7 CSS-072-27",
      "code_information": [
        {
          "code": "3058530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1347,
          "minimum": 460.492,
          "maximum": 977.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 684.2625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110 143110",
      "code_information": [
        {
          "code": "3058543",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 683,
          "minimum": 233.4937,
          "maximum": 495.6531,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 346.9572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EPIDURAL 117\\\" INF 1633902",
      "code_information": [
        {
          "code": "3058611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 689.0079,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.7384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE 10X5",
      "code_information": [
        {
          "code": "3058612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1239,
          "minimum": 423.5706,
          "maximum": 1157.2441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 629.3996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-FLOW 50 COBLATION",
      "code_information": [
        {
          "code": "3058620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1833,
          "minimum": 626.6383,
          "maximum": 1330.2081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 931.1457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ACCOMINIZER 4.0",
      "code_information": [
        {
          "code": "3058623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 531.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 224.5316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STONCUTTER 5.5 7205331",
      "code_information": [
        {
          "code": "3058624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 956,
          "minimum": 279.1622,
          "maximum": 693.7692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 485.6384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3058625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4.0 1864G",
      "code_information": [
        {
          "code": "3058639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 14474.7269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL FLEX MED 27MM",
      "code_information": [
        {
          "code": "3058643",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 523.2901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.7065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-RETRIEVAL 30MM DGN-538-5",
      "code_information": [
        {
          "code": "3058644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 941,
          "minimum": 321.6948,
          "maximum": 682.8837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 478.0186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 2.0MM 5820-010-020",
      "code_information": [
        {
          "code": "3058655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1105,
          "minimum": 377.7607,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 561.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARTHREX ANGEL BMC",
      "code_information": [
        {
          "code": "3058674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDO FEEDING 12FR X 60”",
      "code_information": [
        {
          "code": "3058693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 192.0202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MINI 4.0 283459",
      "code_information": [
        {
          "code": "3058696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1275,
          "minimum": 435.8777,
          "maximum": 925.2675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 647.6872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 FULL RADIUS",
      "code_information": [
        {
          "code": "3058697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1275,
          "minimum": 435.8777,
          "maximum": 925.2675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 647.6872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 018 14MMX34CM",
      "code_information": [
        {
          "code": "3058707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 877.5258,
          "maximum": 3070.4367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2149.3057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-240",
      "code_information": [
        {
          "code": "3058716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1082,
          "minimum": 369.8978,
          "maximum": 785.2074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 549.6452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANOSCOPE-BEVELED DISP 103X18M",
      "code_information": [
        {
          "code": "3058720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 16442.2087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-EXPEL NEPHR I/E 8.3/22",
      "code_information": [
        {
          "code": "3058729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1262,
          "minimum": 431.4335,
          "maximum": 915.8334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 641.0834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH 15FR 71C",
      "code_information": [
        {
          "code": "3058737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 7838.7856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-VPAD 2 INS-0050",
      "code_information": [
        {
          "code": "3058749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2207,
          "minimum": 754.4957,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1121.1339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-ALWAYS ON TIP INS-0352",
      "code_information": [
        {
          "code": "3058751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-19 GA ANSO INS-0382",
      "code_information": [
        {
          "code": "3058752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GA ANSO INS 0392",
      "code_information": [
        {
          "code": "3058753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GA NITINOL INS-5410",
      "code_information": [
        {
          "code": "3058754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4175,
          "minimum": 1227.3127,
          "maximum": 3029.7975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2120.8582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 8MMX24CM",
      "code_information": [
        {
          "code": "3058757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 6MMX17CM",
      "code_information": [
        {
          "code": "3058758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 8523.9008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE DISTRACTOR DISP",
      "code_information": [
        {
          "code": "3058766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 192.8118,
          "maximum": 935.3602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 286.5064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 4MMX7CM",
      "code_information": [
        {
          "code": "3058776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MM X xCM",
      "code_information": [
        {
          "code": "3058777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 32205.4193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 AR 8943-16",
      "code_information": [
        {
          "code": "3058786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1013,
          "minimum": 346.3091,
          "maximum": 2388.4495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 514.5939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPIN EWC BIOPSY GUIDE",
      "code_information": [
        {
          "code": "3058788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3127,
          "minimum": 1069.0114,
          "maximum": 3022.4035,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1588.4847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DISP SHOULDER 1.8MM",
      "code_information": [
        {
          "code": "3058805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1659,
          "minimum": 567.1538,
          "maximum": 1455.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 842.7554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENTRAINER-AIR RT008",
      "code_information": [
        {
          "code": "3058809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.3389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 5.0 5050",
      "code_information": [
        {
          "code": "3058819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58043,
          "minimum": 19842.8621,
          "maximum": 42121.8051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29485.2636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 7.0 7050",
      "code_information": [
        {
          "code": "3058820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60044,
          "minimum": 99.5419,
          "maximum": 43573.9308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30501.7516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 BV-1 M8709",
      "code_information": [
        {
          "code": "3058836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 379.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 6MM X xxCM",
      "code_information": [
        {
          "code": "3058840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 2MMXxxCM",
      "code_information": [
        {
          "code": "3058843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4220,
          "minimum": 1442.6697,
          "maximum": 3062.454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2143.7178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX20CM",
      "code_information": [
        {
          "code": "3058844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5064,
          "minimum": 1731.2037,
          "maximum": 3674.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2572.4614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX30CM",
      "code_information": [
        {
          "code": "3058845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5591,
          "minimum": 1911.3664,
          "maximum": 4057.3887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2840.1721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 CX ALL",
      "code_information": [
        {
          "code": "3058847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HEATED AIRVO 900PT501",
      "code_information": [
        {
          "code": "3058860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 181.8447,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 363.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO SM OPT942",
      "code_information": [
        {
          "code": "3058861",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.1127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO MED OPT944",
      "code_information": [
        {
          "code": "3058862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.1127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO LARGE OPT946",
      "code_information": [
        {
          "code": "3058863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 86.1955,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.1127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-013-000 SZ4",
      "code_information": [
        {
          "code": "3058864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.7384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HEALING W/PLUG 30MM 95084",
      "code_information": [
        {
          "code": "3058868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 42.8197,
          "maximum": 156.7512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 109.7258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.5MM",
      "code_information": [
        {
          "code": "3058875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CONTOUR CERVICAL 13-15",
      "code_information": [
        {
          "code": "3058876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 61.7271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-RIB UNIVERSAL 8” MALE",
      "code_information": [
        {
          "code": "3058877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.2587,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3.0 1893G",
      "code_information": [
        {
          "code": "3058878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 66.1759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MMX15CM",
      "code_information": [
        {
          "code": "3058884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 129.5713,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SLIM MED",
      "code_information": [
        {
          "code": "3058885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 79.6545,
          "maximum": 216.3229,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 118.3617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-SYSTEM UA2007",
      "code_information": [
        {
          "code": "3058887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 162,
          "minimum": 55.3821,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WATER SUCTION BIOPSY VALVE",
      "code_information": [
        {
          "code": "3058903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.0387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-ACCUSTAT 125NM S 801015",
      "code_information": [
        {
          "code": "3058929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5081,
          "minimum": 280.8305,
          "maximum": 3687.2817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2581.0972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MIDLINE 5FR BIO FLO",
      "code_information": [
        {
          "code": "3058932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 1.4X27MM",
      "code_information": [
        {
          "code": "3058955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3358,
          "minimum": 1147.9822,
          "maximum": 12836.4563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1705.8304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON,CAPIOX HPH-1000",
      "code_information": [
        {
          "code": "3058981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 291.2689,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 432.8075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOBLADE GASTRO",
      "code_information": [
        {
          "code": "3058983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5049,
          "minimum": 522.734,
          "maximum": 3664.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2564.8415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORTHOLOCK 3X110MM EX",
      "code_information": [
        {
          "code": "3058990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 319.6436,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 474.9706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X 343MM",
      "code_information": [
        {
          "code": "3058991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1159,
          "minimum": 396.2214,
          "maximum": 841.0863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.7604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y935H",
      "code_information": [
        {
          "code": "3059006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.0X40X91MM",
      "code_information": [
        {
          "code": "3059015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 526.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-GENESYS HTA M006580211",
      "code_information": [
        {
          "code": "3059026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6769,
          "minimum": 870.8526,
          "maximum": 4912.2633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3438.5843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-CLEANING STICK 900PT602",
      "code_information": [
        {
          "code": "3059061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 93.4248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-QUADFUSE 9” EXT SMALLBORE",
      "code_information": [
        {
          "code": "3059062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 1661.0707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.3423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED OPT316",
      "code_information": [
        {
          "code": "3059066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 522,
          "minimum": 178.4535,
          "maximum": 401.5042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 265.1708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-HEADREST SOFTOUCH",
      "code_information": [
        {
          "code": "3059127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 12074.0432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.4987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ESOPHYX TIF R2007",
      "code_information": [
        {
          "code": "3059129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21712,
          "minimum": 1866.2716,
          "maximum": 15756.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11029.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTER CONNECT PT-5558-F",
      "code_information": [
        {
          "code": "3059131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 722.93,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.5753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 3.5X195 700353",
      "code_information": [
        {
          "code": "3059137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1228,
          "minimum": 419.81,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 623.8117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACQUIRE EUS FND",
      "code_information": [
        {
          "code": "3059156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 497.7095,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1346.6815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 2.0MM BIT",
      "code_information": [
        {
          "code": "3059170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2114,
          "minimum": 279.1622,
          "maximum": 1534.1298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1073.8909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-IMPLANT SIZING SG - x",
      "code_information": [
        {
          "code": "3059171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 6595.346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIALYZER-HIGH FLUX 1.6 720DH16",
      "code_information": [
        {
          "code": "3059177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 859.1745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ULTRAPERC FULL 100/573/000",
      "code_information": [
        {
          "code": "3059178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1545,
          "minimum": 30.5855,
          "maximum": 1121.2065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 784.8445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT MED",
      "code_information": [
        {
          "code": "3059179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 2180.4681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.9394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENVEO PRO LOADING",
      "code_information": [
        {
          "code": "3059185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2618,
          "minimum": 255.806,
          "maximum": 1899.8826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1329.9178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 1.5MM NEEDLES",
      "code_information": [
        {
          "code": "3059187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 460,
          "minimum": 157.2578,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 233.6754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-VERTEX DRILL 2.4MM",
      "code_information": [
        {
          "code": "3059197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 18503.6714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN 5X5CM FUD021",
      "code_information": [
        {
          "code": "3059209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-KNOTLESS S-TAK STEP 3MM",
      "code_information": [
        {
          "code": "3059213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW OSC SAGITTAL xxMM",
      "code_information": [
        {
          "code": "3059220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 8367.0806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 316.9858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO DURACLIP 235CM 11MM",
      "code_information": [
        {
          "code": "3059232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 16632.951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 716.2659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT LG",
      "code_information": [
        {
          "code": "3059245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 39.9135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.9394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT SM",
      "code_information": [
        {
          "code": "3059246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 2632.0213,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.9394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-POLAR COMBO 1232PP",
      "code_information": [
        {
          "code": "3059252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 907,
          "minimum": 310.0714,
          "maximum": 780.2083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 460.7469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-TRI STAPLE 2.0 SIG30AVM",
      "code_information": [
        {
          "code": "3059259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2871,
          "minimum": 981.494,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1458.4393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND 1.0MM",
      "code_information": [
        {
          "code": "3059273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 151.2592,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 648.7032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION MED",
      "code_information": [
        {
          "code": "3059281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 279,
          "minimum": 95.3803,
          "maximum": 4504.9661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 15\\\" ADJ ILIO",
      "code_information": [
        {
          "code": "3059288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 328,
          "minimum": 112.1317,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.6207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP ALL",
      "code_information": [
        {
          "code": "3059603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 2352.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT 111645",
      "code_information": [
        {
          "code": "3059922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 266.3127,
          "maximum": 664.5395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 395.7242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X140 143140",
      "code_information": [
        {
          "code": "3059924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1195,
          "minimum": 408.5285,
          "maximum": 2945.1056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 607.048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ABC SINGLE FUNCTION",
      "code_information": [
        {
          "code": "3059973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 850,
          "minimum": 290.5851,
          "maximum": 726.2666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 431.7915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATCHER-STONE WITH TUB 840-750",
      "code_information": [
        {
          "code": "3059984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 825,
          "minimum": 282.0385,
          "maximum": 4179.6476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 419.0917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP       7-382",
      "code_information": [
        {
          "code": "3059989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 6650.3999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.6552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ISOLATOR  BIP   OSL2",
      "code_information": [
        {
          "code": "3059996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11959,
          "minimum": 627.8369,
          "maximum": 8678.6463,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6075.0524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-LINEAR 60GRN      TX60G",
      "code_information": [
        {
          "code": "3060001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 913,
          "minimum": 305.855,
          "maximum": 662.5641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 463.7949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM GREEN        XR60G",
      "code_information": [
        {
          "code": "3060002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 550,
          "minimum": 84.5272,
          "maximum": 399.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 279.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE   RC014MIBB",
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        {
          "code": "3060082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 68.9564,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 474.9706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CORONARY PERFUSN 10004",
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        {
          "code": "3060083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 477.1338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.9908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEX IRIS     611.75",
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        {
          "code": "3060129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 858,
          "minimum": 175.1715,
          "maximum": 622.6506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 435.8554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 8\\\"  7708-000-10",
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        {
          "code": "3060132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 228.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 160.0168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VESSEL           30003",
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        {
          "code": "3060134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 101,
          "minimum": 34.5284,
          "maximum": 1063.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-T-TUBE 16FR       0099830",
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        {
          "code": "3060199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 825.2524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE MEDIUM   9893",
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        {
          "code": "3060289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 170.2487,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 252.979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-UNIV     60-6010-001",
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        {
          "code": "3060315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 68.9564,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 274.3146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERZ-REFLECTIVE PK   PM 8005",
      "code_information": [
        {
          "code": "3060317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 143.4738,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 62.9908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-SPRING CLIP 6MM  CSOFT6",
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        {
          "code": "3060318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 131.0614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-SILVERSTEIN PK 1428010",
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        {
          "code": "3060385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 71.4498,
          "maximum": 12457.1961,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 106.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0 CT-2 Z332H",
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        {
          "code": "3060417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 71.6266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROGRAMMER-TEST STIM 3531",
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        {
          "code": "3060442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2604,
          "minimum": 259.1426,
          "maximum": 1889.7228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1322.806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MINI HOOK 357501",
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        {
          "code": "3060443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 159.309,
          "maximum": 414.2945,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 236.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 4.0MM 03.000.012S",
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        {
          "code": "3060451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 745,
          "minimum": 254.6893,
          "maximum": 540.6465,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 378.4525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 5.0MM 03.000.015S",
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        {
          "code": "3060452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 184.607,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90X9.5 05.003.126S",
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        {
          "code": "3060455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 1953.0232,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 316.9858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 10M",
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        {
          "code": "3060460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3512,
          "minimum": 398.1676,
          "maximum": 2548.6584,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1784.0609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT",
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        {
          "code": "3060472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 363.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 5MM PAL-508LL",
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        {
          "code": "3060475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 1614.9144,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 375.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-FAST FIX 360 KPSC",
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        {
          "code": "3060478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1344,
          "minimum": 459.4664,
          "maximum": 975.3408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 682.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU RIGHT 7210424",
      "code_information": [
        {
          "code": "3060485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1334,
          "minimum": 456.0477,
          "maximum": 968.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 677.6587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU LEFT 7210423",
      "code_information": [
        {
          "code": "3060486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 657.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STRT 7210426",
      "code_information": [
        {
          "code": "3060488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 657.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.3MM CROSSPIN 62-23333",
      "code_information": [
        {
          "code": "3060489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 742.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STR 7210425",
      "code_information": [
        {
          "code": "3060494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 909.3021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 636.5115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SILICONE 8CM        205108",
      "code_information": [
        {
          "code": "3061090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1750,
          "minimum": 598.2635,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 888.9825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-SINGLE HOLE 1877-01-010",
      "code_information": [
        {
          "code": "3062492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2040,
          "minimum": 95.6492,
          "maximum": 1480.428,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-3' EPV100 VENT",
      "code_information": [
        {
          "code": "3068320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX PEDS MAXP",
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        {
          "code": "3068323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 54.3565,
          "maximum": 283.0549,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP VIBRATORY ACAPELLA",
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        {
          "code": "3068325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 31.6977,
          "maximum": 369.3813,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED W/7' TUBING",
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        {
          "code": "3068327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BIPAP PERFORMATRAK LARGE",
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        {
          "code": "3068330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 35.5904,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT DUAL LIMB",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT CAPNOXYGEN C02-01",
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        {
          "code": "3068332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 25.9817,
          "maximum": 102.3224,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT/PED 8’ 58051",
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        {
          "code": "3068333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 62.9031,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-MYOSURE            40-902",
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        {
          "code": "3078533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 58.4589,
          "maximum": 3316.5804,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-DURA           20-xxxx",
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        {
          "code": "3078541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "maximum": 4328.0748,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-DURAL           1314",
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        {
          "code": "3078593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 244.7752,
          "maximum": 868.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 363.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH INDWELLING SLIT 295-6",
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        {
          "code": "3078730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 533.9929,
          "maximum": 1133.5434,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-KARLEN BALLOON    CS-01700",
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        {
          "code": "3078823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 207.4253,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML 0797208",
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        {
          "code": "3078850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 276.3817,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 113.2818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU, DIALYSIS 2.5% 2L 5B9876",
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        {
          "code": "3078852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 28.3611,
          "maximum": 360.6729,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML  07138-09",
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        {
          "code": "3078858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 17.4351,
          "maximum": 865.8477,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK E3773-45C",
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        {
          "code": "3078982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 428.6985,
          "maximum": 1022.6679,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 637.0195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MAS TLIF LIGHT   3400033",
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        {
          "code": "3079040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 636.1784,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MULTILEAD TRIAL     3013",
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        {
          "code": "3079055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 391.0934,
          "maximum": 830.2008,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.0X13        AR-8400EX",
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        {
          "code": "3079215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 155.5485,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.-X13 AR-8500EX",
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        {
          "code": "3079228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 155.2066,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER        20400161S/10",
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          "code": "3079240",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 99.5419,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL G2 TIP 35CM",
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        {
          "code": "3079250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 364.8016,
          "maximum": 2415.8553,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 ABRADER    72201518",
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        {
          "code": "3079252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 224.2633,
          "maximum": 476.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR    72201513",
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        {
          "code": "3079253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 217.7679,
          "maximum": 462.2709,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
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        {
          "code": "3079254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 204.4352,
          "maximum": 433.9686,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5 FULL RADIUS 7205305",
      "code_information": [
        {
          "code": "3079257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 155.5485,
          "maximum": 498.2656,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 231.1354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 FULL RADIUM 7205306",
      "code_information": [
        {
          "code": "3079261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 224.5316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 INCISOR     7205345",
      "code_information": [
        {
          "code": "3079262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 1761.1687,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 224.5316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL 45CM    NSLG2C45A",
      "code_information": [
        {
          "code": "3079282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3167,
          "minimum": 1082.686,
          "maximum": 2298.2919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1608.8043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 36\\\"   HAR36",
      "code_information": [
        {
          "code": "3079285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3146,
          "minimum": 1075.5068,
          "maximum": 2283.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1598.1365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HS FOCUS 9CM CRVD  HAR9F",
      "code_information": [
        {
          "code": "3079290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2871,
          "minimum": 680.1103,
          "maximum": 2083.4847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1458.4393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INPUT 8FR PS    080011",
      "code_information": [
        {
          "code": "3079468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 425.9726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.2271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNLER SM-LG    9009-s",
      "code_information": [
        {
          "code": "3079475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 766,
          "minimum": 261.8685,
          "maximum": 555.8862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 389.1203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-RENAL 20CM      900-123",
      "code_information": [
        {
          "code": "3079482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 313.5024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 219.4517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-EXT BILATERAL DYNJP8004A",
      "code_information": [
        {
          "code": "3079499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 2033.1016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-CORNEAL DISP      E5699",
      "code_information": [
        {
          "code": "3079626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-CAROTID ALL     2000-00s",
      "code_information": [
        {
          "code": "3079680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 6136.0074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909504",
      "code_information": [
        {
          "code": "3079703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11962,
          "minimum": 2091.4921,
          "maximum": 8680.8234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6076.5764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5070",
      "code_information": [
        {
          "code": "3079707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3761,
          "minimum": 1285.7537,
          "maximum": 2729.3577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1910.5504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5071",
      "code_information": [
        {
          "code": "3079709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3761,
          "minimum": 1285.7537,
          "maximum": 11631.3876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1910.5504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PHACO .9MM  8065-750517",
      "code_information": [
        {
          "code": "3079736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 429,
          "minimum": 146.66,
          "maximum": 7567.9649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 217.9277,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SMALL VIT PLUS 1",
      "code_information": [
        {
          "code": "3079745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1675,
          "minimum": 572.6236,
          "maximum": 7567.9649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 850.8832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STAR            AR-1606",
      "code_information": [
        {
          "code": "3079766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 877,
          "minimum": 299.8155,
          "maximum": 636.4389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 445.5072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 12MM        CB12LT",
      "code_information": [
        {
          "code": "3079770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1106,
          "minimum": 378.1025,
          "maximum": 8681.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 561.8369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM KII          CFS22",
      "code_information": [
        {
          "code": "3079789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.6459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-FIBER          AR-7209SN",
      "code_information": [
        {
          "code": "3079790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 80.0784,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM KII           CFS02",
      "code_information": [
        {
          "code": "3079791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 114.5566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.1506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM THREADED KII CTS22",
      "code_information": [
        {
          "code": "3079792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.6459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM THREADED KII  CTS0S",
      "code_information": [
        {
          "code": "3079793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 165.1617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.1825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATABLE OVAL",
      "code_information": [
        {
          "code": "3079795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 297,
          "minimum": 101.5339,
          "maximum": 8681.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 150.873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SILICONE         400561",
      "code_information": [
        {
          "code": "3079975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 550,
          "minimum": 188.0257,
          "maximum": 399.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 279.3945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER MINI        1500",
      "code_information": [
        {
          "code": "3079992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 425.9859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 298.1901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER SMALL       1500",
      "code_information": [
        {
          "code": "3079994",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 554,
          "minimum": 189.3931,
          "maximum": 402.0378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 281.4265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER PETITE      1500",
      "code_information": [
        {
          "code": "3079996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 8572.8376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 298.1901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-AGGRESSIVE 3.5   283315",
      "code_information": [
        {
          "code": "3080062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 291.0783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ULTRA AGGRESSIVE 283325",
      "code_information": [
        {
          "code": "3080067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 1213.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 291.0783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.5MM AR-1204AS-95",
      "code_information": [
        {
          "code": "3080073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2182,
          "minimum": 745.9491,
          "maximum": 1583.4774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1108.4342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 10MM AR-1204AS-100",
      "code_information": [
        {
          "code": "3080074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1582.7517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1107.9262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.0MM AR1204AS90",
      "code_information": [
        {
          "code": "3080075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1819,
          "minimum": 207.4253,
          "maximum": 1320.0483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 924.0338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-OPTIMOLD NASAL   PS1688",
      "code_information": [
        {
          "code": "3080204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 195.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.9748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3080355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 352,
          "minimum": 113.4444,
          "maximum": 255.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.8125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-EGIA 60 MED   EGIA60AVM",
      "code_information": [
        {
          "code": "3080925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 477.6899,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 796.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-ENDOCLIP MULTI    ER320",
      "code_information": [
        {
          "code": "3080932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 859,
          "minimum": 293.6619,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 436.3634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR VASCULAR  TX30V",
      "code_information": [
        {
          "code": "3081085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 81.7467,
          "maximum": 697.3977,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 488.1784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT 12”",
      "code_information": [
        {
          "code": "3081101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.6745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT RIGHT",
      "code_information": [
        {
          "code": "3081102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.6745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY RT ANGLE Y PORT 12”",
      "code_information": [
        {
          "code": "3081103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 117.8932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.6745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIEDER TS101DC",
      "code_information": [
        {
          "code": "3081129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 594,
          "minimum": 203.0677,
          "maximum": 5771.7619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 301.7461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-POLYSORB 55      SZ 200",
      "code_information": [
        {
          "code": "3081173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4940,
          "minimum": 497.1534,
          "maximum": 3584.958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2509.4706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN INSORB 2030",
      "code_information": [
        {
          "code": "3081400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 894,
          "minimum": 305.6272,
          "maximum": 4780.7917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.1431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZS ECS's",
      "code_information": [
        {
          "code": "3081408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1763,
          "minimum": 602.7077,
          "maximum": 4780.7917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 895.5864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZ CDHxxA",
      "code_information": [
        {
          "code": "3081415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1570,
          "minimum": 536.7278,
          "maximum": 1451.9771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 797.5443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWER  PLEE60A",
      "code_information": [
        {
          "code": "3081416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2611,
          "minimum": 892.6091,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1326.3619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-INTERNAL EEA   EEAXL25",
      "code_information": [
        {
          "code": "3081425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1376.3475,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWERED PCE60A",
      "code_information": [
        {
          "code": "3081432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2475,
          "minimum": 846.1155,
          "maximum": 1796.1075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1257.2752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 45       EC45A",
      "code_information": [
        {
          "code": "3081433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2038,
          "minimum": 696.7206,
          "maximum": 1478.9766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1035.2836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 60       EC60A",
      "code_information": [
        {
          "code": "3081436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2635,
          "minimum": 900.8139,
          "maximum": 1912.2195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1338.5536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-EGIA HANDLE  EGIAUSTND",
      "code_information": [
        {
          "code": "3081443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2985,
          "minimum": 1020.4666,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1516.3501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDO GIA UNIVER 030449",
      "code_information": [
        {
          "code": "3081491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 464.8996,
          "maximum": 1915.848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1341.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-THICK TISSUE      TRT75",
      "code_information": [
        {
          "code": "3081494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3752.0067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.6796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3081502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 61.171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT STR 35WD",
      "code_information": [
        {
          "code": "3081503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAYS-SURGICAL PACK    3311-8G",
      "code_information": [
        {
          "code": "3081506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER   TLC-75",
      "code_information": [
        {
          "code": "3081530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 60BL      TX60B",
      "code_information": [
        {
          "code": "3081535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 904,
          "minimum": 309.0458,
          "maximum": 1678.8659,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR  40B     CS40B",
      "code_information": [
        {
          "code": "3081542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3019,
          "minimum": 1032.09,
          "maximum": 2190.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1533.6218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40G      CS40G",
      "code_information": [
        {
          "code": "3081544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3019,
          "minimum": 1032.09,
          "maximum": 2190.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1533.6218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDOPATH VASC PVE35A",
      "code_information": [
        {
          "code": "3081550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2231,
          "minimum": 762.7005,
          "maximum": 1619.0367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1133.3257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-HEAVY WIRE 90    TLH90",
      "code_information": [
        {
          "code": "3081554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 791,
          "minimum": 270.4151,
          "maximum": 574.0287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 401.8201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3081569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 12302.6003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.2271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A28-2",
      "code_information": [
        {
          "code": "3082047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21603,
          "minimum": 7385.3066,
          "maximum": 15677.2971,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10974.108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A25-25",
      "code_information": [
        {
          "code": "3082066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21603,
          "minimum": 7385.3066,
          "maximum": 15677.2971,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10974.108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-AAA MAIN    ETCF3636C49E",
      "code_information": [
        {
          "code": "3082068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 20042,
          "minimum": 6851.6555,
          "maximum": 14544.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10181.1356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STICK-FIBER            AR-7209",
      "code_information": [
        {
          "code": "3082089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 27356.7834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKINETTE-BARRIER   NON22535",
      "code_information": [
        {
          "code": "3082135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 366.4699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE FOOT        014407",
      "code_information": [
        {
          "code": "3082217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 659,
          "minimum": 225.2889,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 334.7654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRAIGHT           1123",
      "code_information": [
        {
          "code": "3082330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 198.8418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 139.1893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUMP-PERICARDIAL 1/4 CONNECTOR",
      "code_information": [
        {
          "code": "3082395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 164.6056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.9462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURG-STRIP 1/2X6       80-1451",
      "code_information": [
        {
          "code": "3082416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 296,
          "minimum": 101.192,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 150.365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPRALOOP-BRUCKER/MESSROGHLI",
      "code_information": [
        {
          "code": "3082421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1727,
          "minimum": 498.2656,
          "maximum": 1253.2839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 877.2987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-NUKNITT 3X4      1943",
      "code_information": [
        {
          "code": "3082430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 455.159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC-0       173024",
      "code_information": [
        {
          "code": "3082450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 625.5534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 437.8874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC 2-0 173023",
      "code_information": [
        {
          "code": "3082453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 207.4253,
          "maximum": 625.5534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 437.8874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 698G",
      "code_information": [
        {
          "code": "3082542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 235.2303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.5593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-GORETEX CV-3      3N06A",
      "code_information": [
        {
          "code": "3082544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 423,
          "minimum": 144.6088,
          "maximum": 306.9711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.8798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J947H",
      "code_information": [
        {
          "code": "3082558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 4065.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.5114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONO PDSII        Z740D",
      "code_information": [
        {
          "code": "3082562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 305,
          "minimum": 104.2688,
          "maximum": 221.3385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.9369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ALIANCE        5060-05",
      "code_information": [
        {
          "code": "3082566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 1441.4112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.9883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-FLOSEAL 10ML   1503352",
      "code_information": [
        {
          "code": "3082592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2592,
          "minimum": 886.1137,
          "maximum": 5547.0975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1316.7101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING NEMA   3730ANS",
      "code_information": [
        {
          "code": "3082996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2006.0525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ACCESSORY           502",
      "code_information": [
        {
          "code": "3083003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4011,
          "minimum": 1371.22,
          "maximum": 2910.7827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2037.5479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BIOGLUE 5ML  BG3515-5US",
      "code_information": [
        {
          "code": "3083007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5122,
          "minimum": 760.7448,
          "maximum": 3717.0354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2601.9248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANS CATH 10\\\" PM040-A",
      "code_information": [
        {
          "code": "3083014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1368,
          "minimum": 467.6711,
          "maximum": 992.7576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 694.9303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-CYSTO 25X5/8  581610",
      "code_information": [
        {
          "code": "3083019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 50,
          "minimum": 17.0932,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 25.3995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE VNUS        CFP",
      "code_information": [
        {
          "code": "3083021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.8192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION CATH  PM010-A",
      "code_information": [
        {
          "code": "3083022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 435,
          "minimum": 148.7112,
          "maximum": 333.1039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.9756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION 5\\\"    PM020-A",
      "code_information": [
        {
          "code": "3083023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 304.286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-COLLECTION   003984-901",
      "code_information": [
        {
          "code": "3083083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 69.7404,
          "maximum": 867.516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-STERIDRAPE 8 7/8   1075",
      "code_information": [
        {
          "code": "3083104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 832.4817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URETERAL DIAL   240-100",
      "code_information": [
        {
          "code": "3083141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1497,
          "minimum": 511.7717,
          "maximum": 1086.3729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 760.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-PROTACK DEVICE 5MM",
      "code_information": [
        {
          "code": "3083191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3464,
          "minimum": 331.4356,
          "maximum": 2513.8248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1759.6774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB AR-13226",
      "code_information": [
        {
          "code": "3083200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 596,
          "minimum": 203.7515,
          "maximum": 575.5635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 302.762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-BONE SCREW 3.5X50  311.349",
      "code_information": [
        {
          "code": "3083203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 1343.5376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 525.7696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.35 2883-02-043",
      "code_information": [
        {
          "code": "3083212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 522.734,
          "maximum": 1753.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1227.3038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-IQ DISPOSABLE 72-1010",
      "code_information": [
        {
          "code": "3083214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 310.8599,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 477.5106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-TVT DEVICE .5\\\"X18\\\" 810041",
      "code_information": [
        {
          "code": "3083229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5520.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-          AR-7237-7T",
      "code_information": [
        {
          "code": "3083486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 520,
          "minimum": 177.7697,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 264.1548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS2",
      "code_information": [
        {
          "code": "3083597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 134.5762,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.8192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-BIOGLUE FAN        BGST-12",
      "code_information": [
        {
          "code": "3083615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 82.7313,
          "maximum": 593.3587,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.9336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE ALL    UMx67x's",
      "code_information": [
        {
          "code": "3083622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1067,
          "minimum": 207.4253,
          "maximum": 774.3219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 542.0253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 35CM     3908",
      "code_information": [
        {
          "code": "3083637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 236.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CURVED DISP I&A 8065751512",
      "code_information": [
        {
          "code": "3083715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE POLYMER I/A",
      "code_information": [
        {
          "code": "3083720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 222,
          "minimum": 75.894,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 112.7738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-TURBOSONICS     8065750853",
      "code_information": [
        {
          "code": "3083760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 50.6051,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 379.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EMBLEM TUNNELING 4711",
      "code_information": [
        {
          "code": "3084601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5623.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-LUKI MUCOUS SPEC  8646-04",
      "code_information": [
        {
          "code": "3084800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 6",
      "code_information": [
        {
          "code": "3084821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 321.353,
          "maximum": 726.2666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 477.5106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA70",
      "code_information": [
        {
          "code": "3084824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.4349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA80",
      "code_information": [
        {
          "code": "3084827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1345,
          "minimum": 100.098,
          "maximum": 976.0665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 683.2465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/METER ALL P4PxxSD",
      "code_information": [
        {
          "code": "3084870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 130.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.4382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CHG PREP        DYND70663",
      "code_information": [
        {
          "code": "3084874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "TRAY-BETADINE PREP   DYND70672",
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        {
          "code": "3084876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 26.3236,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1    4609764",
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        {
          "code": "3084884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 52.6472,
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAPS-FINGER DISP PACK 9900s",
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        {
          "code": "3084885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-LAP CB EXPLOR    G26908",
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        {
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        },
        {
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          "type": "RC"
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      ],
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        {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SOLU IRRISEPT .5% CHG",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP 26-23-0757",
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          "code": "3084992",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 96.4059,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFF74",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 503.8266,
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-100LP",
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        {
          "code": "3085111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 174.6154,
          "maximum": 657.4842,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED     CTF73",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-100L",
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          "code": "3085113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREATED      CTF03",
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        {
          "code": "3085117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-8MM KII OPTICAL   COQ19",
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        {
          "code": "3085120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 91.9616,
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII FIOS     CFFxx",
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        {
          "code": "3085125",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "3085130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR47",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR85",
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          "code": "3085137",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM KII OPTICAL  COR37",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM LONG         C0R39",
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        {
          "code": "3085142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 149.5909,
          "maximum": 411.4719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 288.0303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM KII FIOS      CFFxx",
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        {
          "code": "3085145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM LONG BLADED CFB71",
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        {
          "code": "3085160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 107.3456,
          "maximum": 490.4802,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 159.5089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-THORACOPOR 11.5  179303",
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        {
          "code": "3085163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 178.5081,
          "maximum": 640.0674,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM THREADED     CTF33",
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        {
          "code": "3085165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 163.0648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-SPLIT           82-4095",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "TROCAR-XCEL BLADELESS     B8LT",
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          "code": "3085202",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 164.7789,
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP LONG VS101505",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 467.3293,
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 5MM           B5LT",
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        {
          "code": "3085207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 390.3822,
          "maximum": 1119.7551,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 783.8286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BIO PREP BONE PREP",
      "code_information": [
        {
          "code": "3085533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1349,
          "minimum": 100.6541,
          "maximum": 978.9693,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 685.2785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 8.0FR MEGA IAB",
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        {
          "code": "3085537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1496,
          "minimum": 511.4298,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 759.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ARMSTRONG TEFLON DRAIN",
      "code_information": [
        {
          "code": "3085540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 113.2818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-TIBIAL 111651",
      "code_information": [
        {
          "code": "3085541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 757.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 216.4037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PROCEDURE TRACKING 107130",
      "code_information": [
        {
          "code": "3085542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 225.2205,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 691.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE 111320",
      "code_information": [
        {
          "code": "3085543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 405,
          "minimum": 138.4553,
          "maximum": 454.3337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 205.7359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX IMPACTION",
      "code_information": [
        {
          "code": "3085544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 817,
          "minimum": 279.3036,
          "maximum": 592.8969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 415.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144140",
      "code_information": [
        {
          "code": "3085545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 685.7865,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 480.0505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON ULTRASIL",
      "code_information": [
        {
          "code": "3085560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.5627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-ENDO EXCEL 15MM   B15LT",
      "code_information": [
        {
          "code": "3085620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1548,
          "minimum": 529.2068,
          "maximum": 1123.3836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 786.3685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR ARMSTRONG    10-56121",
      "code_information": [
        {
          "code": "3085635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 155.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 108.7099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR PAPARELLA 1.14MM",
      "code_information": [
        {
          "code": "3085636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 881.4185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 108.7099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACHEAL EMG  8229307",
      "code_information": [
        {
          "code": "3085638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1585,
          "minimum": 88.976,
          "maximum": 1150.2345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 805.1641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH ALL SZS 822970x",
      "code_information": [
        {
          "code": "3085644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2759,
          "minimum": 207.9814,
          "maximum": 2002.2063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1401.5444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 20FR   0100-20",
      "code_information": [
        {
          "code": "3085648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 491.0363,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.9883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-KAMVAC            5300-00",
      "code_information": [
        {
          "code": "3085723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 301.8667,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 448.5552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MOSS GASTROSTOMY  5-17719",
      "code_information": [
        {
          "code": "3085779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 375.9236,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 937.7495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T MODIFIED        24-0072",
      "code_information": [
        {
          "code": "3085882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 230.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 161.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COLLECTION DISP BKT-506",
      "code_information": [
        {
          "code": "3086006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 83.415,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OXYFLEX        SA008000",
      "code_information": [
        {
          "code": "3086095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX INFLOW  AQL-110",
      "code_information": [
        {
          "code": "3086102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      80-9102",
      "code_information": [
        {
          "code": "3086103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 715,
          "minimum": 99.5419,
          "maximum": 518.8755,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 363.2128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      5120-10",
      "code_information": [
        {
          "code": "3086105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 535.5243,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 116.3297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AIRSEAL ASM-EVAC",
      "code_information": [
        {
          "code": "3086106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 963,
          "minimum": 301.4062,
          "maximum": 698.8491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 489.1944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATOR STR  18-95522",
      "code_information": [
        {
          "code": "3086107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 542,
          "minimum": 43.3758,
          "maximum": 393.3294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.3306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LASER VACUUM    VT10424",
      "code_information": [
        {
          "code": "3086109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 93.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.6232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LIPOSUCTION   DYND50112",
      "code_information": [
        {
          "code": "3086110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 425.4165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MAIN PUMP       AR-6410",
      "code_information": [
        {
          "code": "3086111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 99.5419,
          "maximum": 555.1605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 388.6123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/4\\\"X1/16\\\"X8'      3108",
      "code_information": [
        {
          "code": "3086139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 132,
          "minimum": 45.1262,
          "maximum": 279.1622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.0547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OUTFLOW         AR-6430",
      "code_information": [
        {
          "code": "3086141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO      284508",
      "code_information": [
        {
          "code": "3086142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 450,
          "minimum": 153.8392,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 228.5955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO IRRIG OUT",
      "code_information": [
        {
          "code": "3086144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 109.5517,
          "maximum": 441.9513,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 309.3659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-ASPIRATION AT-10003-6",
      "code_information": [
        {
          "code": "3086181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 349.7869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TISSEEL         0600065",
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        {
          "code": "3086182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 629,
          "minimum": 112.8883,
          "maximum": 456.4653,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 319.5257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TRANSDUCER 48 61000",
      "code_information": [
        {
          "code": "3086185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 165.7178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARTHREX-TIB CANN      AR-1802D",
      "code_information": [
        {
          "code": "3086190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 456.5581,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 151.381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-& TIP-SMALL   9009-18",
      "code_information": [
        {
          "code": "3086203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 821,
          "minimum": 280.6711,
          "maximum": 595.7997,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 417.0598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER & TIP-LARGE   9009-16",
      "code_information": [
        {
          "code": "3086205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 724,
          "minimum": 247.5102,
          "maximum": 1804.5445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 367.7848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-STIMULATOR LEAD   402",
      "code_information": [
        {
          "code": "3086210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3245,
          "minimum": 207.4253,
          "maximum": 2354.8965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1648.4275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE SUPPORT 79-82160",
      "code_information": [
        {
          "code": "3086407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 504.9388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 70x-xxxx ALL SIZES",
      "code_information": [
        {
          "code": "3086409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 341.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.1001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH 2-0   170057",
      "code_information": [
        {
          "code": "3086965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 813,
          "minimum": 277.9361,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 412.9959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VAC-SUPER TURBO     ASC4250-01",
      "code_information": [
        {
          "code": "3087110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 58.9466,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 742.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP CVD ALL 21500s",
      "code_information": [
        {
          "code": "3087119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CURVED 7MM     21853",
      "code_information": [
        {
          "code": "3087130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 72.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 50.799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 8MM CVD   20317",
      "code_information": [
        {
          "code": "3087132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 2133.1996,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VOICE-PROLARYN        8044M0K5",
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        {
          "code": "3087140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3836,
          "minimum": 1311.3936,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1948.6496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVULATOME-LEMAITRE   1009-00",
      "code_information": [
        {
          "code": "3087919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 13534,
          "minimum": 870.8526,
          "maximum": 9821.6238,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 6875.1367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8916-14",
      "code_information": [
        {
          "code": "3087939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 812,
          "minimum": 277.5943,
          "maximum": 589.2684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 412.4879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 UNDYED    VLOCM1904",
      "code_information": [
        {
          "code": "3088955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 7.7854,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 274.8226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J761D",
      "code_information": [
        {
          "code": "3088965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 309.7477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.4542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VIOLET    VLOCM0804",
      "code_information": [
        {
          "code": "3088967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 557,
          "minimum": 58.9466,
          "maximum": 404.2149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 282.9504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0    MCP496G",
      "code_information": [
        {
          "code": "3088972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 7.7854,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J441",
      "code_information": [
        {
          "code": "3088976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 34.4782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6.0959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS2     1666G",
      "code_information": [
        {
          "code": "3088979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.4954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J218H",
      "code_information": [
        {
          "code": "3088985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 8.7084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6.0959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y495G",
      "code_information": [
        {
          "code": "3088991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 444.3239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       D5526",
      "code_information": [
        {
          "code": "3088992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 799,
          "minimum": 35.5904,
          "maximum": 579.8343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 405.884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 6-0           Z432H",
      "code_information": [
        {
          "code": "3088993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 7.7854,
          "maximum": 46.4448,
          "payers_information": [
            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0  ALL  833-000s",
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        {
          "code": "3088998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 386.7981,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J727D",
      "code_information": [
        {
          "code": "3089002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 7.7854,
          "maximum": 126.9975,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J905T",
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        {
          "code": "3089005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 39.9982,
          "maximum": 97.3175,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J739D",
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        {
          "code": "3089007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL 0          J906G",
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        {
          "code": "3089013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 50.596,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J740D",
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        {
          "code": "3089014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J775D",
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        {
          "code": "3089024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 120.1176,
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            {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL 2-0        J789D",
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        {
          "code": "3089025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 45.6002,
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      ],
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    },
    {
      "description": "SUTURE-PDS 1             Z881G",
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        {
          "code": "3089026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 28.0329,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8806H",
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        {
          "code": "3089027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 53.3856,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z990G",
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        {
          "code": "3089030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 7.7854,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J834G",
      "code_information": [
        {
          "code": "3089039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J833G",
      "code_information": [
        {
          "code": "3089042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8824G",
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        {
          "code": "3089048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 42.8163,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 29.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y493G",
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        {
          "code": "3089059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y490G",
      "code_information": [
        {
          "code": "3089060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 72.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8521H",
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        {
          "code": "3089064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8581H",
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        {
          "code": "3089065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 35.5539,
          "maximum": 75.4728,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8557H",
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        {
          "code": "3089066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "3089069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "3089072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 20.8538,
          "maximum": 55.0539,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "3089073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 33.8446,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-PROLENE 3-0       8534H",
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        {
          "code": "3089074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 37.947,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "3089079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      PX82H",
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        {
          "code": "3089097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 31.7934,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "3089100",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 30.7678,
          "maximum": 112.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8706H",
      "code_information": [
        {
          "code": "3089103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 103.122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8805H",
      "code_information": [
        {
          "code": "3089105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 76.2359,
          "maximum": 161.8311,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 113.2818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8709H",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 90.9361,
          "maximum": 193.0362,
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          ]
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    },
    {
      "description": "SUTURE-PROLENE 5-0       8720H",
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        {
          "code": "3089110",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 50.6051,
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    },
    {
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          "code": "3089113",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          ]
        }
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    },
    {
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        {
          "code": "3089114",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "code": "0270",
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        }
      ],
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        {
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    {
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      ],
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            }
          ]
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        {
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    },
    {
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          ]
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    },
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      ],
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-CHROMIC 4-0       U203",
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        {
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      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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      ],
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        {
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          "minimum": 32.819,
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            }
          ]
        }
      ],
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    },
    {
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        {
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      ],
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            }
          ]
        }
      ],
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    },
    {
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        {
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      ],
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          ]
        }
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      ],
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            }
          ]
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    },
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      ],
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            }
          ]
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    },
    {
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      ],
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            }
          ]
        }
      ],
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    },
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        {
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      ],
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            }
          ]
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      ],
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    },
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        {
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      ],
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            }
          ]
        }
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    },
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        }
      ],
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          ]
        }
      ],
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      ],
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            }
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        }
      ],
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    },
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      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
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        }
      ],
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        {
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          "minimum": 23.2468,
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            {
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            }
          ]
        }
      ],
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    },
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1663H",
      "code_information": [
        {
          "code": "3089244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z340H",
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        {
          "code": "3089254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 7.7854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 0         L880G",
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        {
          "code": "3089258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      SXP82",
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        {
          "code": "3089266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 207.512,
          "maximum": 440.4999,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "3089267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 7.7854,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X927H",
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        {
          "code": "3089281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z879G",
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        {
          "code": "3089283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0 Z494G",
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        {
          "code": "3089284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 28.7166,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y497G",
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        {
          "code": "3089286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 31.1097,
          "maximum": 66.0387,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0        687G",
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        {
          "code": "3089287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X513H",
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        {
          "code": "3089288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 21.5375,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 32.0034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2 MX69G",
      "code_information": [
        {
          "code": "3089290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 73.8428,
          "maximum": 215.2107,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS O EZ10G",
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        {
          "code": "3089291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 132.3017,
          "maximum": 280.8459,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          EJ10G",
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        {
          "code": "3089292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       M8720",
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          "code": "3089293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 212.6399,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       M8303",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       U202H",
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        {
          "code": "3089307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 30.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U213H",
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        {
          "code": "3089308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 19.4863,
          "maximum": 49.4929,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 28.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8843H",
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        {
          "code": "3089314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 30.426,
          "maximum": 100.6541,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 45.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J555G",
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        {
          "code": "3089316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            C027D",
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        {
          "code": "3089318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX45D",
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        {
          "code": "3089320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 70.766,
          "maximum": 150.2199,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 105.1539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 8-0         2815G",
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        {
          "code": "3089323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 35.0343,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X523H",
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        {
          "code": "3089324",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 21.5375,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 32.0034,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X977H",
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        {
          "code": "3089325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 30.0841,
          "maximum": 63.8616,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 5-0     1915G",
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        {
          "code": "3089326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 36.5795,
          "maximum": 167.9422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0           Z774D",
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        {
          "code": "3089328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 10-0      9003G",
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        {
          "code": "3089335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 7.7854,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.5694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        793G",
      "code_information": [
        {
          "code": "3089348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 192,
          "minimum": 37.8148,
          "maximum": 139.3344,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 699G",
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        {
          "code": "3089354",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON/MONO    ETH562H",
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        {
          "code": "3089357",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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      "service_type": "CDM"
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    {
      "description": "SUTURE-VICRYL 2-0 CT1  J-945-H",
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          "code": "3089362",
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          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 3.4186,
          "maximum": 33.366,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0        585H",
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        {
          "code": "3089363",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 20.5119,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C0125",
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        {
          "code": "3089364",
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 27.0073,
          "maximum": 179.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMD2B413",
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        {
          "code": "3089371",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 110.0805,
          "maximum": 233.6754,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPD2B408",
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          "code": "3089372",
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
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          "minimum": 34.4782,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "SUTURE-CHROMIC 3-0       U204H",
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        {
          "code": "3089379",
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        {
          "code": "0270",
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        {
          "setting": "inpatient",
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          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J428H",
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        {
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        {
          "code": "0270",
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      ],
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        {
          "setting": "inpatient",
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          "maximum": 38.3709,
          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6/0 P-1    J489G",
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          "code": "0270",
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 7-0        J488G",
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        {
          "code": "3089384",
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        {
          "code": "0270",
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPP1A400",
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        {
          "code": "3089386",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 370,
          "minimum": 99.5419,
          "maximum": 268.509,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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          ]
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      ],
      "service_type": "CDM"
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    {
      "description": "SUTURE-ETHIBOND 2.0 ALL PX83Hs",
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          "code": "3089390",
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1654G",
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          "code": "3089394",
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
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      "service_type": "CDM"
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    {
      "description": "SUTURE-NUROLON 4-0       C584D",
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        {
          "code": "3089396",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 236,
          "minimum": 80.6801,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPD2B413",
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        {
          "code": "3089403",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 48.9368,
          "maximum": 283.7487,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z493G",
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        {
          "code": "3089407",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN 4-0 1644G",
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        {
          "code": "3089408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE RS23",
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          "code": "3089410",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.8575,
          "maximum": 378.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC PBT xxMM",
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          "code": "3089416",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "minimum": 232.81,
          "maximum": 1362.445,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 129.9086,
          "maximum": 275.766,
          "payers_information": [
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
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        }
      ],
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        {
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          "minimum": 127.1737,
          "maximum": 1121.6537,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 689.5414,
          "maximum": 1463.7369,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-TURBINATE RED EICA4845-01",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 701.8486,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,TOPAZ MICRO ACH4041-0",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .045      WS-1106ST",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 91.9616,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER #2          AR-7200",
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        {
          "code": "3091195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 183.3844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER 2-0         AR-7220",
      "code_information": [
        {
          "code": "3091196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.3844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5         310.243",
      "code_information": [
        {
          "code": "3091211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 291.2689,
          "maximum": 618.2964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 432.8075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6MM AGK16150",
      "code_information": [
        {
          "code": "3091237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 236.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-2.5MM DRILL XFO082501",
      "code_information": [
        {
          "code": "3091238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 796.0203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE          1806-0080S",
      "code_information": [
        {
          "code": "3091250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1197,
          "minimum": 207.4253,
          "maximum": 868.6629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 608.064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3091317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.4004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .054          WS-1406ST",
      "code_information": [
        {
          "code": "3091319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K              0152-0218S",
      "code_information": [
        {
          "code": "3091346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 881,
          "minimum": 99.5419,
          "maximum": 639.3417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 447.5392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 040-365",
      "code_information": [
        {
          "code": "3091419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1510,
          "minimum": 198.5277,
          "maximum": 1095.807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 767.0649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 046-072",
      "code_information": [
        {
          "code": "3091422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 357,
          "minimum": 122.0458,
          "maximum": 259.0749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.3524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY    047-032",
      "code_information": [
        {
          "code": "3091425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 295,
          "minimum": 100.8501,
          "maximum": 342.5576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 149.857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE TIP      03.211.410",
      "code_information": [
        {
          "code": "3091436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 616,
          "minimum": 157.3763,
          "maximum": 447.0312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 312.9218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 5.0 310.63",
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        {
          "code": "3091500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3340,
          "minimum": 55.61,
          "maximum": 2423.838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1696.6866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 21665",
      "code_information": [
        {
          "code": "3091501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-PROGEL PGPS002",
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        {
          "code": "3091508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 494.929,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION SEID",
      "code_information": [
        {
          "code": "3091510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 890,
          "minimum": 304.2597,
          "maximum": 645.873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 452.1111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND M 2.5MM 03.000.007S",
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        {
          "code": "3091511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 105.659,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 402.3281,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/2X3/32 /10 3610",
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        {
          "code": "3091513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 190,
          "minimum": 64.9543,
          "maximum": 645.076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.5181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLUE-GUN CMS REVOLUTION",
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        {
          "code": "3091516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1029,
          "minimum": 351.7789,
          "maximum": 1269.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 522.7217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT 5MM EB210",
      "code_information": [
        {
          "code": "3091517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 1656.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1159.2332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT FINE EB230",
      "code_information": [
        {
          "code": "3091518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2953,
          "minimum": 313.6404,
          "maximum": 2142.9921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1500.0945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE CANNU FLEX .042X12",
      "code_information": [
        {
          "code": "3091560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 121.2298,
          "maximum": 409.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 286.5064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TEMPORARY CARDIA  024-100",
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        {
          "code": "3091561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 158.2026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8MM FIBULA ROD 80-0642",
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        {
          "code": "3091572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.4349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-FACIAL DENTAL 714-6IN-GEL",
      "code_information": [
        {
          "code": "3093187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 249,
          "minimum": 85.1244,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 126.4895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ACCESSORY       3550-02",
      "code_information": [
        {
          "code": "3093195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 207.4253,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 477.5106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOBUTTON-CL ULTRA PAC 1.2",
      "code_information": [
        {
          "code": "3094000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2461,
          "minimum": 841.3294,
          "maximum": 1785.9477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1250.1634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACCESSORY-TIP COVER     400180",
      "code_information": [
        {
          "code": "3100010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.5089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SNAPFIT 15 DEG    400152",
      "code_information": [
        {
          "code": "3102750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 363.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCL0316",
      "code_information": [
        {
          "code": "3115410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 184.9489,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 274.8226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCM1545",
      "code_information": [
        {
          "code": "3115420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 184.9489,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 274.8226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA ARM        420279",
      "code_information": [
        {
          "code": "3115515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA HEAD       420273",
      "code_information": [
        {
          "code": "3115525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM    420015",
      "code_information": [
        {
          "code": "3115580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM XI 470015",
      "code_information": [
        {
          "code": "3115585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 652,
          "minimum": 156.8202,
          "maximum": 473.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 331.2095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM LONG XI   470358",
      "code_information": [
        {
          "code": "3155025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 272.8632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.0042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM XI        470357",
      "code_information": [
        {
          "code": "3155030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 272.8632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.0042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 5MM        400161",
      "code_information": [
        {
          "code": "3170005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.0295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 8.5-13MM   420206",
      "code_information": [
        {
          "code": "3170007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 124.5664,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.8192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA            400077",
      "code_information": [
        {
          "code": "3170010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 113.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA ENDOWRIST XI",
      "code_information": [
        {
          "code": "3170020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.5089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-8MM XI 570361",
      "code_information": [
        {
          "code": "3170050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL s.I.e.    410322",
      "code_information": [
        {
          "code": "3170060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 1147.6403,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1705.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL XI        480322",
      "code_information": [
        {
          "code": "3170070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 170.1666,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1705.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUB. & FILTER 20400162S/10",
      "code_information": [
        {
          "code": "3171250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 306,
          "minimum": 104.6106,
          "maximum": 222.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 155.4449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-ENDOWRIST STAPLER 45",
      "code_information": [
        {
          "code": "3171320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 6652.0682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.5089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909506",
      "code_information": [
        {
          "code": "3171350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11962,
          "minimum": 976.5116,
          "maximum": 8680.8234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6076.5764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 12M OMS-T12BT",
      "code_information": [
        {
          "code": "3175750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1756,
          "minimum": 600.3147,
          "maximum": 1274.3292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 892.0304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-SINGLE SITE 8.5    428065",
      "code_information": [
        {
          "code": "3185345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1488,
          "minimum": 508.6949,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 755.8891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEXIBLE         3100A",
      "code_information": [
        {
          "code": "3240013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1449,
          "minimum": 201.3082,
          "maximum": 1051.5393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 736.0775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GENERATOR INFANT LP FLOW",
      "code_information": [
        {
          "code": "3240072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 596,
          "minimum": 203.7515,
          "maximum": 432.5172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 302.762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INFANT O2 DELIVERY   RT329",
      "code_information": [
        {
          "code": "3240073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 476,
          "minimum": 62.2832,
          "maximum": 345.4332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 241.8032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RESUS S/USE       900RD010",
      "code_information": [
        {
          "code": "3240075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 433.758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG HYDROGEL",
      "code_information": [
        {
          "code": "3240083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODES-EEG LOW IMPEDENCE",
      "code_information": [
        {
          "code": "3240085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 72.8491,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.9883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTERFACE-TRACHEOSTOMY HI FLOW",
      "code_information": [
        {
          "code": "3240105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 273.0451,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.1127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BELLOWS & WATER TRAP 3100A",
      "code_information": [
        {
          "code": "3240167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 177.3959,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 455.159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CONNECTING TUBING.   3100",
      "code_information": [
        {
          "code": "3240170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 319,
          "minimum": 109.0549,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.0488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 6 FR    196",
      "code_information": [
        {
          "code": "3249995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 8 FR    198",
      "code_information": [
        {
          "code": "3249997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE MAC 5FR    1925",
      "code_information": [
        {
          "code": "3249998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 138.6087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.0261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE 14FR 12\\\" 220135",
      "code_information": [
        {
          "code": "3250000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.9748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT UNCUFFED",
      "code_information": [
        {
          "code": "3281990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 47.8246,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 455.159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3282370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XS      006950",
      "code_information": [
        {
          "code": "3283013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 196.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.4702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP THERAPY  \\\"ACAPELLA\\\"",
      "code_information": [
        {
          "code": "3283015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 111.22,
          "maximum": 256.8978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 179.8285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION  LG     006965",
      "code_information": [
        {
          "code": "3283017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 101.598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XLG     006970",
      "code_information": [
        {
          "code": "3283018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 101.598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUVETTE-CO2 DISP ADULT MP01062",
      "code_information": [
        {
          "code": "3284354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 198,
          "minimum": 53.9417,
          "maximum": 143.6886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER 5MM",
      "code_information": [
        {
          "code": "3290045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 176.8398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL MED HIGH FLOW",
      "code_information": [
        {
          "code": "3290046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 230.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 161.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL SM HIGH FLOW",
      "code_information": [
        {
          "code": "3290047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL LG HIGH FLOW",
      "code_information": [
        {
          "code": "3290048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP           23-0757",
      "code_information": [
        {
          "code": "3290060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 91.2004,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT L599-130",
      "code_information": [
        {
          "code": "3290061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 205.757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT W/MR290 SINGLE",
      "code_information": [
        {
          "code": "3290062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 370,
          "minimum": 126.49,
          "maximum": 268.509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 187.9563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BREATHING NEONATAL",
      "code_information": [
        {
          "code": "3290074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.5307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-INFANT DUAL FLOW RT26",
      "code_information": [
        {
          "code": "3290077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 82.3028,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 224.5316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOWMETER-PEAK          002068",
      "code_information": [
        {
          "code": "3290080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 107.4036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.1825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-CPAP NASAL NSC-001",
      "code_information": [
        {
          "code": "3290082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOW-CONT CYSTO GREENLYT",
      "code_information": [
        {
          "code": "3290084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 102.3224,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP MED",
      "code_information": [
        {
          "code": "3290127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 133.5288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.4702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP SMALL",
      "code_information": [
        {
          "code": "3290128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 133.5288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.4702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOSE-AIR MODEL 205 DISP",
      "code_information": [
        {
          "code": "3290145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 174.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED SM NIV",
      "code_information": [
        {
          "code": "3290170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.0009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED MED NIV",
      "code_information": [
        {
          "code": "3290171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.0009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED LG NIV",
      "code_information": [
        {
          "code": "3290172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 56.7222,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.0009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 42MM    RD804-10",
      "code_information": [
        {
          "code": "3290178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP AIRLIFE W/FILTER",
      "code_information": [
        {
          "code": "3290184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 171.8349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.9109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL XS INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 309,
          "minimum": 105.6362,
          "maximum": 224.2413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 156.9689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL LG INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.5089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL MED INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 206.8245,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.7771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 308,
          "minimum": 58.3905,
          "maximum": 223.5156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 156.4609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 60MM    RD806-10",
      "code_information": [
        {
          "code": "3290194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 76.1985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.3389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK,OXY ADULT OM-1125-8",
      "code_information": [
        {
          "code": "3290214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 149.0348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED SMALL NIV",
      "code_information": [
        {
          "code": "3290215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.1413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED LARGE NIV",
      "code_information": [
        {
          "code": "3290217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.1413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 78.9708,
          "maximum": 167.6367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 117.3457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED LG NIV",
      "code_information": [
        {
          "code": "3290219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 391.4944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.5374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP ALOHA ALO100",
      "code_information": [
        {
          "code": "3290220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 704,
          "minimum": 66.1759,
          "maximum": 510.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 357.625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-MISTY FINITY  002534",
      "code_information": [
        {
          "code": "3290245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 119,
          "minimum": 40.6819,
          "maximum": 422.636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 60.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOPPER-DECANNULATION SZ4",
      "code_information": [
        {
          "code": "3290354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 760,
          "minimum": 194.635,
          "maximum": 551.532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 386.0724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DIRECTIONAL BALLARD  22059",
      "code_information": [
        {
          "code": "3290385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 388.7139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.0707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 5MM PROX",
      "code_information": [
        {
          "code": "3290400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 699,
          "minimum": 238.9635,
          "maximum": 507.2643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 355.085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY SLT UNCUFF 5MM",
      "code_information": [
        {
          "code": "3290401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 679,
          "minimum": 232.1262,
          "maximum": 492.7503,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 344.9252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEST-SPU ALL SZS  WRAP-SLOTTED",
      "code_information": [
        {
          "code": "3290504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 819,
          "minimum": 279.9873,
          "maximum": 594.3483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 416.0438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING WHITE    PMV005",
      "code_information": [
        {
          "code": "3290506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 876,
          "minimum": 299.4736,
          "maximum": 635.7132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 444.9992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING PURPLE  PMV2001",
      "code_information": [
        {
          "code": "3290508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 875,
          "minimum": 33.366,
          "maximum": 634.9875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 444.4912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP LPEEP",
      "code_information": [
        {
          "code": "3290509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP ADJ          2K8082",
      "code_information": [
        {
          "code": "3290515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 265.2597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-THERAPRESSURE     262895",
      "code_information": [
        {
          "code": "3300010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 51,
          "minimum": 17.4351,
          "maximum": 582.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 25.9075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOFT GOODS FOR CPM UNIT",
      "code_information": [
        {
          "code": "3302945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 325.8746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.1287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA VARICEX S",
      "code_information": [
        {
          "code": "3310024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.1632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-ENDURA KIT         775410",
      "code_information": [
        {
          "code": "3310985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.7065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BGE   A840235",
      "code_information": [
        {
          "code": "3310986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 91.4382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BLACK  554617",
      "code_information": [
        {
          "code": "3310987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 53.6728,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX RED   A840241",
      "code_information": [
        {
          "code": "3310989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 89.9868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.9908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 6CMX5CM",
      "code_information": [
        {
          "code": "3310991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.1472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 8CMX5CM",
      "code_information": [
        {
          "code": "3310992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 10CMX5M",
      "code_information": [
        {
          "code": "3310993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 60.9588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDL K 12CMX5M",
      "code_information": [
        {
          "code": "3311000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 100.098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.5786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL 15CMX.4CMX2.5M",
      "code_information": [
        {
          "code": "3311010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 161.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.4382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ12 12CM",
      "code_information": [
        {
          "code": "3311075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 290,
          "minimum": 84.5272,
          "maximum": 210.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 147.3171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ7 7CM",
      "code_information": [
        {
          "code": "3311076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.2145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL SOFT",
      "code_information": [
        {
          "code": "3311078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 126.2347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING C",
      "code_information": [
        {
          "code": "3311085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 164.7339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AID-\\\"CLEAN EASY\\\" GRIP REACH",
      "code_information": [
        {
          "code": "3311086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 203.196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.2372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING D",
      "code_information": [
        {
          "code": "3311094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 391.4944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3311107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 29.4733,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-LG HDL      C6298-01-25",
      "code_information": [
        {
          "code": "3311117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 53,
          "minimum": 18.1188,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.9235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3311123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.1612,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 6CMX5M",
      "code_information": [
        {
          "code": "3311138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 74.5174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 8CMX5M RL",
      "code_information": [
        {
          "code": "3311139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 44.488,
          "maximum": 97.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.0707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-IONTOPHOR IOGEL 2971",
      "code_information": [
        {
          "code": "3311144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 58.3905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYBRESIS PATCH",
      "code_information": [
        {
          "code": "3311150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 33.366,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALU 1.5X3.5 PK 2393",
      "code_information": [
        {
          "code": "3311153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 86.1955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ALUM LTX FREE ALL",
      "code_information": [
        {
          "code": "3311156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.7384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXERCISER-POWER GRIP HAND",
      "code_information": [
        {
          "code": "3311157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 63.5869,
          "maximum": 402.0603,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.4861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-COMFY HAND/THUMB",
      "code_information": [
        {
          "code": "3311158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 723,
          "minimum": 28.3611,
          "maximum": 524.6811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 367.2768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3311161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 37.2587,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUTRODE RND 1.25\\\"",
      "code_information": [
        {
          "code": "3311163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT OVAL PK 2\\\"X4\\\"",
      "code_information": [
        {
          "code": "3311164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.5913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-WEIGHTED EZ GRIP 920675",
      "code_information": [
        {
          "code": "3311165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 91.7565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELECTRODE ADULT       9050",
      "code_information": [
        {
          "code": "3311167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 141.8055,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.8183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3311174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 36.7026,
          "maximum": 185.0535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.5374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT SQ PK  1.5X3.5",
      "code_information": [
        {
          "code": "3311178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 293.0647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.5273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT M&LGE",
      "code_information": [
        {
          "code": "3311191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 48.3807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.5114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARD-FOOD INVISIBLE      1115",
      "code_information": [
        {
          "code": "3311192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 87.3077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.1951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-TRACTION EXER ALL C5032s",
      "code_information": [
        {
          "code": "3311193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 35.5904,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT S&XS",
      "code_information": [
        {
          "code": "3311194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 280.2744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.5114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LAVAGE    0210112000",
      "code_information": [
        {
          "code": "3311197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 504,
          "minimum": 172.2999,
          "maximum": 365.7528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 256.027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPM SOFTGOOD FOR HOME UNIT",
      "code_information": [
        {
          "code": "3311235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 238.7553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.1287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3311250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 319,
          "minimum": 104.5468,
          "maximum": 231.4983,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.0488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HIP/KNEE W/26 REACHER",
      "code_information": [
        {
          "code": "3311251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH UPPER EXTREMITY",
      "code_information": [
        {
          "code": "3311255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 28.9172,
          "maximum": 134.9802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.4861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-ELASTO-GEL CAST/SPL  A8273",
      "code_information": [
        {
          "code": "3311340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 65.0637,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.4155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3311347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3311357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 87.8638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-D WRIST BRACE ALL SIZES",
      "code_information": [
        {
          "code": "3311363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.2624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADDING-FOAM \\\"KOMPREX\\\" SHEET",
      "code_information": [
        {
          "code": "3311369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPOON-WEIGHTED EZ GRIP 920688",
      "code_information": [
        {
          "code": "3311406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-LONG-32\\\"       A665009",
      "code_information": [
        {
          "code": "3311472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 28.9172,
          "maximum": 84.9069,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-ALUMINUM 32\\\"      4107",
      "code_information": [
        {
          "code": "3311475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 37.7364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.4155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-STANDARD 26\\\"    A80-42",
      "code_information": [
        {
          "code": "3311479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.5114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-SAMMONS PRESTON   4109",
      "code_information": [
        {
          "code": "3311480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINTING-EZEFORM 1/8”X18”X24”",
      "code_information": [
        {
          "code": "3311600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 475,
          "minimum": 92.3126,
          "maximum": 344.7075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 241.2952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELBOW NEOPRENE XL",
      "code_information": [
        {
          "code": "3311602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 166,
          "minimum": 56.7496,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.3263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-JOINT JACK MED   A52542",
      "code_information": [
        {
          "code": "3311613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 203.9217,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.7452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 6\\\"-7\\\"",
      "code_information": [
        {
          "code": "3311625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 174.2406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 3-14",
      "code_information": [
        {
          "code": "3311701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT S/M A812731",
      "code_information": [
        {
          "code": "3311702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 188.9723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND COMFY LG ADULT",
      "code_information": [
        {
          "code": "3311703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 444,
          "minimum": 151.788,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 225.5476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT/LARGE DYNAPRO",
      "code_information": [
        {
          "code": "3311704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 379.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-STABILIZER WALKER ROLYAN",
      "code_information": [
        {
          "code": "3311708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 463,
          "minimum": 158.2834,
          "maximum": 335.9991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 235.1994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WALKER HIGH OVATION LRG",
      "code_information": [
        {
          "code": "3311709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 549,
          "minimum": 23.3562,
          "maximum": 398.4093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 278.8865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-LMB FINGER HUGGER",
      "code_information": [
        {
          "code": "3312530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 83.7569,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 124.4575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EZEFORM-ANTI MICROBIAL 564393",
      "code_information": [
        {
          "code": "3315521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 572,
          "minimum": 121.7859,
          "maximum": 415.1004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 290.5703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3397811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 349,
          "minimum": 47.2685,
          "maximum": 253.2693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.2885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PALM SHIELD RIGHT",
      "code_information": [
        {
          "code": "3397815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.5307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND RIGHT/MED A31228",
      "code_information": [
        {
          "code": "3397817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 226.4184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 158.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT MED A31227",
      "code_information": [
        {
          "code": "3397818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 78.9662,
          "maximum": 226.4184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 158.4929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-SKIN DERMABOND  DNX12",
      "code_information": [
        {
          "code": "3500034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 99.5419,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SOFTGOODS CPM        20533",
      "code_information": [
        {
          "code": "3500038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 46.1563,
          "maximum": 235.8525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.0967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "3500087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.1632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LMA DISP ALL SZ  1250xx",
      "code_information": [
        {
          "code": "3500245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 91.7565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 34FR  123034",
      "code_information": [
        {
          "code": "3500275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 38.3709,
          "maximum": 119.7405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.8183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 28F   123028",
      "code_information": [
        {
          "code": "3500280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 26FR  123026",
      "code_information": [
        {
          "code": "3500283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 30FR  123030",
      "code_information": [
        {
          "code": "3500285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 32FR  123032",
      "code_information": [
        {
          "code": "3500288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACMENT KNEE COLD L/XL",
      "code_information": [
        {
          "code": "3500410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 7.7854,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP   260815",
      "code_information": [
        {
          "code": "3500759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 127,
          "minimum": 43.4168,
          "maximum": 243.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.5147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED & 60MM AIRWAY",
      "code_information": [
        {
          "code": "3500786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT & 90MM AIRWY",
      "code_information": [
        {
          "code": "3500788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 38.927,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASPIRATOR-MECONIUM HCI   N0101",
      "code_information": [
        {
          "code": "3500789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 88.4199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.5593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-INFANT  5442160xx",
      "code_information": [
        {
          "code": "3500792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 42.8197,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-COLLECTION 4X8 BX     9778",
      "code_information": [
        {
          "code": "3500815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 55.8789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    C0135T",
      "code_information": [
        {
          "code": "3501012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 7.7854,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0        697H",
      "code_information": [
        {
          "code": "3501065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 57.3303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 FS-3  1665G",
      "code_information": [
        {
          "code": "3501070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 249.1328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.4954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXTERNAL CSF DRAIN INS8700",
      "code_information": [
        {
          "code": "3501130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 448,
          "minimum": 99.5419,
          "maximum": 325.1136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 227.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC VERALNK ULTLNK500",
      "code_information": [
        {
          "code": "3501755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 666,
          "minimum": 83.415,
          "maximum": 483.3162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 338.3213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18FR5CC 0119L18",
      "code_information": [
        {
          "code": "3501790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 31.6977,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC       6261",
      "code_information": [
        {
          "code": "3502002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 91.2004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EFFLUENT 5L PRISMAFLEX",
      "code_information": [
        {
          "code": "3502007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 20F30C  0167L20",
      "code_information": [
        {
          "code": "3502010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 205.2009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.1506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL   TCS1000",
      "code_information": [
        {
          "code": "3502048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 369,
          "minimum": 60.0588,
          "maximum": 267.7833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 187.4483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 400     7000LL",
      "code_information": [
        {
          "code": "3502063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 1283.4788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST MED RIGHT 5001-0",
      "code_information": [
        {
          "code": "3502580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 118.2891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.8024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LARGE RT  5001-04",
      "code_information": [
        {
          "code": "3502590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 704.0226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.8024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-LIFEBAND FOR AUTOPULSE",
      "code_information": [
        {
          "code": "3502593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1266,
          "minimum": 93.4248,
          "maximum": 918.7362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 643.1153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST X-LG LT 5001-10",
      "code_information": [
        {
          "code": "3502600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.3423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-FLEXMASTER 6\\\" 79-98718",
      "code_information": [
        {
          "code": "3502681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 304.1867,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.8343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF C",
      "code_information": [
        {
          "code": "3502706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 547,
          "minimum": 187.0001,
          "maximum": 396.9579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 277.8705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF D",
      "code_information": [
        {
          "code": "3502707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 475,
          "minimum": 162.3858,
          "maximum": 344.7075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 241.2952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-BUNNY W/FRAME & LINER",
      "code_information": [
        {
          "code": "3502709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 351,
          "minimum": 119.9946,
          "maximum": 254.7207,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.3045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-LEG FULL SM 9128-01",
      "code_information": [
        {
          "code": "3502720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 345,
          "minimum": 90.6443,
          "maximum": 250.3665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.2565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3502751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 47.2685,
          "maximum": 118.2891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.8024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMIN 46-62 13992000",
      "code_information": [
        {
          "code": "3503080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 377.5919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-HOOD ALL  0408-8xx-000",
      "code_information": [
        {
          "code": "3503348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 679,
          "minimum": 35.5904,
          "maximum": 492.7503,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 344.9252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ENV INFANT   8004-01",
      "code_information": [
        {
          "code": "3503370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 686.2274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.5114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT ARM",
      "code_information": [
        {
          "code": "3504148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.5307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT BOOT",
      "code_information": [
        {
          "code": "3504149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.5307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT FULL LENGTH",
      "code_information": [
        {
          "code": "3504150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 88.5354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.9748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED ARM",
      "code_information": [
        {
          "code": "3504151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED BOOT",
      "code_information": [
        {
          "code": "3504152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 12\\\" 13960000*",
      "code_information": [
        {
          "code": "3504230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER EYE        607120",
      "code_information": [
        {
          "code": "3504353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 96.7614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MAC 3&4",
      "code_information": [
        {
          "code": "3504355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 126.2718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MIL 2&3",
      "code_information": [
        {
          "code": "3504357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 126.2718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "3504552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 96.5181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.5627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1.5\\\" CT\\\"",
      "code_information": [
        {
          "code": "3504553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 181.2886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.5627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM      100 1974",
      "code_information": [
        {
          "code": "3504663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 326,
          "minimum": 45.0441,
          "maximum": 236.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.6047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM     12-7 1972",
      "code_information": [
        {
          "code": "3504665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.1472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CHANNELED         KVL03C",
      "code_information": [
        {
          "code": "3504905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST EZWALK XL 2001-05",
      "code_information": [
        {
          "code": "3505035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 35.5904,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST STAT ALL 2001-00s",
      "code_information": [
        {
          "code": "3505545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 55.0539,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA TENDERWRAP 4\\\"X10YDS",
      "code_information": [
        {
          "code": "3505570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 156.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WAFFLE  ALL SIZES    FW's",
      "code_information": [
        {
          "code": "3505575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.7452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2515H****",
      "code_information": [
        {
          "code": "3505815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 4263.0626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICAL MED",
      "code_information": [
        {
          "code": "3505906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 83.4555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE HEAVY LARGE",
      "code_information": [
        {
          "code": "3505907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 74.7471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE CHILD   3004-12",
      "code_information": [
        {
          "code": "3505955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 1675.5293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION ATEC",
      "code_information": [
        {
          "code": "3506118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.7191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3506181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-7FR \\\"SLIC\\\"       SC-14701",
      "code_information": [
        {
          "code": "3506470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.6266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CURITY ULTRAMER 6FR  6006",
      "code_information": [
        {
          "code": "3506758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 22G   383591",
      "code_information": [
        {
          "code": "3507108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 90.7125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.4987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 24G   383590",
      "code_information": [
        {
          "code": "3507111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 111.7761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.4987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW ARTERIAL VENOUS",
      "code_information": [
        {
          "code": "3507185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3W 16F 5CC  0119L16",
      "code_information": [
        {
          "code": "3507187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 101.598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.1186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 30CC ALL 123600As",
      "code_information": [
        {
          "code": "3507190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 31.1416,
          "maximum": 93.6153,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.5307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 12 5 165812",
      "code_information": [
        {
          "code": "3507192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 14 5 165814",
      "code_information": [
        {
          "code": "3507193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 16 5 165816",
      "code_information": [
        {
          "code": "3507194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 18 5 165818",
      "code_information": [
        {
          "code": "3507195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 20 5 165820",
      "code_information": [
        {
          "code": "3507196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 22 5 165822",
      "code_information": [
        {
          "code": "3507197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.5114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 24 5 165824",
      "code_information": [
        {
          "code": "3507198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 144.586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18F 0125RL18",
      "code_information": [
        {
          "code": "3507371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 260,
          "minimum": 81.1906,
          "maximum": 188.682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.0774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 20F 30C W/V  0125RL20",
      "code_information": [
        {
          "code": "3507373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 105.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.1665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 22FR/30CC",
      "code_information": [
        {
          "code": "3507381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 146.2543,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 24F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 190.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 133.6014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 26F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 36.7026,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 20FR 30CC      266720",
      "code_information": [
        {
          "code": "3507665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.5273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 24FR 30CC      266724",
      "code_information": [
        {
          "code": "3507670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.6072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3CC   8887603101",
      "code_information": [
        {
          "code": "3507688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 7.7854,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.6072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W  8F  3CC   8887603085",
      "code_information": [
        {
          "code": "3507852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 165.1617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-OXIMETRY 5 LUMEN  5032805",
      "code_information": [
        {
          "code": "3508302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1222,
          "minimum": 399.8359,
          "maximum": 886.8054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 620.7638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SOAKER 1\\\"           PM030",
      "code_information": [
        {
          "code": "3508888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 719,
          "minimum": 90.6443,
          "maximum": 521.7783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 365.2448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-20X1.5 RADIO ARTE RA04220",
      "code_information": [
        {
          "code": "3509147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 32.2538,
          "maximum": 130.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.4382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 16FR  010116",
      "code_information": [
        {
          "code": "3509269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 14FR  010114",
      "code_information": [
        {
          "code": "3509270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN STRAIGHT 18FR",
      "code_information": [
        {
          "code": "3509305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 125.6786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-CHEST DRAIN 9.6FR",
      "code_information": [
        {
          "code": "3509905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 82.8589,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.5694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP ADJ     AA11",
      "code_information": [
        {
          "code": "3509911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 149,
          "minimum": 50.9379,
          "maximum": 108.1293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.6905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-LOW TEMP ADJ      AA02",
      "code_information": [
        {
          "code": "3509912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.1506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3510001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COA 04273",
      "code_information": [
        {
          "code": "3510002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.0295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3510099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 98.5501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEX 72\\\"   DF47x-6121Z",
      "code_information": [
        {
          "code": "3510143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 104.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.1506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENTILATOR COAX",
      "code_information": [
        {
          "code": "3510148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLEANSER-BODY FOAMING REMEDY",
      "code_information": [
        {
          "code": "3510305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCLIP-MEDIUM         523800",
      "code_information": [
        {
          "code": "3510401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.1026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL SMALL 710-SMAL",
      "code_information": [
        {
          "code": "3510714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL MEDIUM 710-MED",
      "code_information": [
        {
          "code": "3510715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 125.5461,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.8823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK PEDI-SELE",
      "code_information": [
        {
          "code": "3510817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL ALL SZ A11500x",
      "code_information": [
        {
          "code": "3510830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3511220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 66.732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.4155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y PRISMAFLEX",
      "code_information": [
        {
          "code": "3511240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 60.9588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISP F/NEOBLUE COZY",
      "code_information": [
        {
          "code": "3511668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FOOT PNEU LRG PR  VP520L",
      "code_information": [
        {
          "code": "3511672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 99.4209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.5946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FT PNEU REGULAR PR VP520",
      "code_information": [
        {
          "code": "3511673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 60.9588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE LTX-FREE   610-002",
      "code_information": [
        {
          "code": "3511677",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 85.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT MED LF/ALUM  7703",
      "code_information": [
        {
          "code": "3511781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 111.7578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.2305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-YOUTH LF/ALUM      7702",
      "code_information": [
        {
          "code": "3511795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 169.0544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3511958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB TALL",
      "code_information": [
        {
          "code": "3511962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 304,
          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FOAM W/COVER    154264",
      "code_information": [
        {
          "code": "3512506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 211,
          "minimum": 72.1335,
          "maximum": 153.1227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.1859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 16-18FR",
      "code_information": [
        {
          "code": "3512575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.7065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.1CM 9231",
      "code_information": [
        {
          "code": "3512760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.1026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.2CM 9232",
      "code_information": [
        {
          "code": "3512761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 131,
          "minimum": 44.7843,
          "maximum": 95.0667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.5467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ANCHOR PICC LNE PIC0220",
      "code_information": [
        {
          "code": "3512770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.5753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 PED PEDI CAP",
      "code_information": [
        {
          "code": "3512773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 722.93,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.8823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RESQPOD 029-12-0242-000",
      "code_information": [
        {
          "code": "3512775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 660.387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FEMOSTOP         11165",
      "code_information": [
        {
          "code": "3512782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 97.3175,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 662.9269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH STABILIZ    DIO120",
      "code_information": [
        {
          "code": "3512792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 126.9975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH SECURMENT VPPDFP",
      "code_information": [
        {
          "code": "3512794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 82.8589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL  SMALL  S-22MM",
      "code_information": [
        {
          "code": "3513121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 149,
          "minimum": 50.9379,
          "maximum": 108.1293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.6905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL MEDIUM  M-29MM",
      "code_information": [
        {
          "code": "3513123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 921.4577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.8343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-ACCU ANTI-REFLUX INS8401",
      "code_information": [
        {
          "code": "3513202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1657,
          "minimum": 215.7668,
          "maximum": 1202.4849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 841.7394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST VALVE PNEUMOSTAT",
      "code_information": [
        {
          "code": "3513225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 40.0392,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.1001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT PRATT        SU130s",
      "code_information": [
        {
          "code": "3513231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.5753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE W/ISO BAG    1003",
      "code_information": [
        {
          "code": "3513475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 108.4395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM SM SIMP CS",
      "code_information": [
        {
          "code": "3514025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 414,
          "minimum": 141.5321,
          "maximum": 300.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 210.3079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM BRIDGE",
      "code_information": [
        {
          "code": "3514230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 640,
          "minimum": 204.0887,
          "maximum": 464.448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 325.1136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-PREVENA 45ML",
      "code_information": [
        {
          "code": "3514251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 367,
          "minimum": 125.4644,
          "maximum": 266.3319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.4323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC 500ML WITH GEL",
      "code_information": [
        {
          "code": "3514255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 413,
          "minimum": 141.1902,
          "maximum": 299.7141,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 209.7999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO MED",
      "code_information": [
        {
          "code": "3514259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1213,
          "minimum": 414.6821,
          "maximum": 880.2741,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 616.1919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO SM",
      "code_information": [
        {
          "code": "3514261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 30.5855,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYME 4X4 5044",
      "code_information": [
        {
          "code": "3514264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 106.2151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.9394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM     10X15CM",
      "code_information": [
        {
          "code": "3514272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 138.6087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.0261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDITRACE 31319281**",
      "code_information": [
        {
          "code": "3514650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 917.0089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 113.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5FR   006173P",
      "code_information": [
        {
          "code": "3514812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1649,
          "minimum": 116.781,
          "maximum": 1196.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 837.6755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-REDIPAK",
      "code_information": [
        {
          "code": "3514819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 210,
          "minimum": 71.7916,
          "maximum": 152.397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 106.6779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLOOD        SQ40S",
      "code_information": [
        {
          "code": "3516138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 97.3175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.9908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTERLINE-INTUBATED SET 185",
      "code_information": [
        {
          "code": "3516160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 175,
          "minimum": 59.8264,
          "maximum": 891.4283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-MR 9GX14CM 20MM",
      "code_information": [
        {
          "code": "3518855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2344,
          "minimum": 318.6453,
          "maximum": 1701.0408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1190.7286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX16CM",
      "code_information": [
        {
          "code": "3518857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 291.0783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX1xCM",
      "code_information": [
        {
          "code": "3518865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 291.0783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX1xCM",
      "code_information": [
        {
          "code": "3518868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX10CM",
      "code_information": [
        {
          "code": "3518870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 578,
          "minimum": 56.7222,
          "maximum": 419.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 293.6182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1962",
      "code_information": [
        {
          "code": "3519300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1034,
          "minimum": 46.7124,
          "maximum": 750.3738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 525.2617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS LF ADLT",
      "code_information": [
        {
          "code": "3519395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.6712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 12F 36\\\"",
      "code_information": [
        {
          "code": "3520193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.0387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 20F 5CC",
      "code_information": [
        {
          "code": "3520196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 129.5713,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.2305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 22FR 20CC",
      "code_information": [
        {
          "code": "3520199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 55.61,
          "maximum": 169.0881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 118.3617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INHALER-DIAMOND SPACR 107-9830",
      "code_information": [
        {
          "code": "3520701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-INTUBATION ALL Gs",
      "code_information": [
        {
          "code": "3521014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1015,
          "minimum": 124.0103,
          "maximum": 736.5855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 515.6098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BARRIER MINOR PROTECTIVE",
      "code_information": [
        {
          "code": "3521441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT FEMORAL 111644",
      "code_information": [
        {
          "code": "3521442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 115.1127,
          "maximum": 309.1482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 216.4037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACOSTOMY PROC ******",
      "code_information": [
        {
          "code": "3521523",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 207,
          "minimum": 70.766,
          "maximum": 664.5395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.1539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH CVP SL       AK-24301",
      "code_information": [
        {
          "code": "3521655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 1142.2294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.6653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRAINAL ACCESS    INS-5HND",
      "code_information": [
        {
          "code": "3521683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2054,
          "minimum": 207.4253,
          "maximum": 1490.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1043.4115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DAILY CARE            6638",
      "code_information": [
        {
          "code": "3521745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.5753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAINAGE PLEURX    50-7510",
      "code_information": [
        {
          "code": "3521755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 43.9319,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 418.5838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DURAPREP SURGICAL     8630",
      "code_information": [
        {
          "code": "3521756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 996.5312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HYPOTHERMIA \\\"KOOL KIT\\\" 900",
      "code_information": [
        {
          "code": "3521917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1792,
          "minimum": 226.3327,
          "maximum": 1300.4544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 910.3181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 6FR AK-09601***",
      "code_information": [
        {
          "code": "3521942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 407,
          "minimum": 139.139,
          "maximum": 295.3599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 206.7519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 8.5 AK-09803CDC",
      "code_information": [
        {
          "code": "3521947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 628,
          "minimum": 43.9319,
          "maximum": 455.7396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 319.0177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGAT CONE/TUBE BX  7721",
      "code_information": [
        {
          "code": "3521963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-SARAH 2778 ALL SIZES",
      "code_information": [
        {
          "code": "3522000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 505,
          "minimum": 142.3616,
          "maximum": 366.4785,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 256.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-HANNAH 2160 ALL SIZES",
      "code_information": [
        {
          "code": "3522002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 256,
          "minimum": 87.5174,
          "maximum": 185.7792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.0454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K ALL SIZES",
      "code_information": [
        {
          "code": "3522003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 707.3592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 146.3011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LUMBAR PUNCTURE    4011015",
      "code_information": [
        {
          "code": "3522152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.1413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MAC CATH MULTI AK-21242CDC",
      "code_information": [
        {
          "code": "3522182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1364,
          "minimum": 392.6066,
          "maximum": 989.8548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 692.8984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 20FR         6820",
      "code_information": [
        {
          "code": "3522270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 358.6409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00568241",
      "code_information": [
        {
          "code": "3522271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 358.6409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KOOL NEONATAL 950",
      "code_information": [
        {
          "code": "3522460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1169,
          "minimum": 399.64,
          "maximum": 848.3433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 593.8403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING ALL",
      "code_information": [
        {
          "code": "3522465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 249.1328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.0387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-MORGAN LTX-FREE    MT2000",
      "code_information": [
        {
          "code": "3522687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 448,
          "minimum": 40.0392,
          "maximum": 325.1136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 227.5795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-4-WAY         4238701",
      "code_information": [
        {
          "code": "3523121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.5753,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND PREMATURE 900643",
      "code_information": [
        {
          "code": "3523139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND MICRO     900644",
      "code_information": [
        {
          "code": "3523140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 50MM    RD805-10",
      "code_information": [
        {
          "code": "3523187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 101,
          "minimum": 34.5284,
          "maximum": 2159.8924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MITT-HAND CONTROL PR  M2023V-A",
      "code_information": [
        {
          "code": "3523675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 69.7404,
          "maximum": 365.3577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTRAOSSEOUS ORANGE",
      "code_information": [
        {
          "code": "3523854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATN     ALL 7700's",
      "code_information": [
        {
          "code": "3523864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 309.1482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 216.4037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX11C",
      "code_information": [
        {
          "code": "3525447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 144.0299,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X13.8 C1616A",
      "code_information": [
        {
          "code": "3525465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 88.543,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.5694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X7.8  C1610A",
      "code_information": [
        {
          "code": "3525466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X7.8  C2010A",
      "code_information": [
        {
          "code": "3525467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "3525468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 352.5674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL STR 17GX4-1/2\\\"",
      "code_information": [
        {
          "code": "3525873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 73.9613,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 20G X 1\\\"",
      "code_information": [
        {
          "code": "3525882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 476.5777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.5627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS G04153",
      "code_information": [
        {
          "code": "3525915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 857,
          "minimum": 136.2445,
          "maximum": 621.9249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 435.3474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-4   DJ4011X",
      "code_information": [
        {
          "code": "3525924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 43.9319,
          "maximum": 177.7965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 124.4575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL PENCAN    333866",
      "code_information": [
        {
          "code": "3525950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 67.8442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX5\\\"    405148",
      "code_information": [
        {
          "code": "3525951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 88.5354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.9748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX7\\\"    405149",
      "code_information": [
        {
          "code": "3525960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X22G",
      "code_information": [
        {
          "code": "3525975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 74.7471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X25G",
      "code_information": [
        {
          "code": "3525976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 418.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PROBLOC 20X100 HN3S-100",
      "code_information": [
        {
          "code": "3526110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 679.5542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.1951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E CATH PLUS 241285-41E",
      "code_information": [
        {
          "code": "3526122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 467,
          "minimum": 159.6509,
          "maximum": 537.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 237.2313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PULSAVAC 00-5150-182-00",
      "code_information": [
        {
          "code": "3526127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 129,
          "minimum": 44.1006,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.5307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL EXTEND 480422",
      "code_information": [
        {
          "code": "3526149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3703,
          "minimum": 1265.9256,
          "maximum": 4248.604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1881.087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-AIRWAY EMMA 17448",
      "code_information": [
        {
          "code": "3526175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 166,
          "minimum": 56.7496,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.3263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.5/2.8",
      "code_information": [
        {
          "code": "3526179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1520,
          "minimum": 464.8996,
          "maximum": 1103.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 772.1448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO xxXxxMM 2.0",
      "code_information": [
        {
          "code": "3526182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 526.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 5800-8-125",
      "code_information": [
        {
          "code": "3526187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1120,
          "minimum": 382.8886,
          "maximum": 812.784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 568.9488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.3MM TWIST QC",
      "code_information": [
        {
          "code": "3526189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 132.3518,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT,-NIFOMETER 10-340-03",
      "code_information": [
        {
          "code": "3526194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 238,
          "minimum": 63.3954,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 120.9016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-NASAL AUTOMATION MAD300",
      "code_information": [
        {
          "code": "3526195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.9109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 70143061",
      "code_information": [
        {
          "code": "3526216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 63.5869,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.4861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT BUTTERFLY 240073",
      "code_information": [
        {
          "code": "3526217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 646.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.5089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER SB4000SA",
      "code_information": [
        {
          "code": "3526218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1162,
          "minimum": 397.247,
          "maximum": 843.2634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 590.2844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SB4040SC",
      "code_information": [
        {
          "code": "3526219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1298,
          "minimum": 443.7406,
          "maximum": 941.9586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 659.371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MALLEABLE MS4000SC",
      "code_information": [
        {
          "code": "3526220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1330,
          "minimum": 99.5419,
          "maximum": 965.181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 675.6267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y936H",
      "code_information": [
        {
          "code": "3526223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 2691.524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CANNULATED 2.0X120MM",
      "code_information": [
        {
          "code": "3526239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1136,
          "minimum": 388.3585,
          "maximum": 9117.8156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICYRL-4-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 7.7854,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X36",
      "code_information": [
        {
          "code": "3526256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 56.7222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X96",
      "code_information": [
        {
          "code": "3526257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 74.0214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-0 PDS PLUS 1X60",
      "code_information": [
        {
          "code": "3526258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 36.5795,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 12X18",
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        {
          "code": "3526259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-4-0 PLUS 1X18",
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        {
          "code": "3526264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 38.6307,
          "maximum": 3337.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRILL 2.0 SPEED HAND WRIS",
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        {
          "code": "3526271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2796,
          "minimum": 955.8541,
          "maximum": 2855.0174,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1420.34,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM ANTERIOR",
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        {
          "code": "3526278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 595,
          "minimum": 203.4096,
          "maximum": 1055.4778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 302.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM     70890832",
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        {
          "code": "3526280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 119,
          "minimum": 40.6819,
          "maximum": 225.7766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT LMA ALL SIZE",
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        {
          "code": "3526297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 24.9561,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURAGAIN SIZE 4",
      "code_information": [
        {
          "code": "3526298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 592.2465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREADED AR-13226T",
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        {
          "code": "3526314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 930,
          "minimum": 317.9343,
          "maximum": 5759.5277,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BATTERY 1.5 50-1010",
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        {
          "code": "3526343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 99.5419,
          "maximum": 666.9183,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC SUPER AK-24301-SK",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 233.8356,
          "maximum": 526.0706,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY 351-3500SZ",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 946,
          "minimum": 323.4042,
          "maximum": 53870.5192,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 480.5585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 115” Y 1637101",
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        {
          "code": "3526361",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 42.3912,
          "maximum": 438.7629,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LITHOTOMY DYNJ31774G",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 269.7314,
          "maximum": 705.6909,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER CLOSED 4MM STRT",
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        {
          "code": "3526366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 433.8265,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER XPEEDA AC-1000729",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAL, X",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 180.5046,
          "maximum": 383.1696,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 268.2187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAl LG",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 180.5046,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 268.2187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-METATRSAL 20MM",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 757.4082,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1534.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.2X1.8X87MM",
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        {
          "code": "3526414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CANN 2.2 A-2716",
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        {
          "code": "3526415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 75.0735,
          "maximum": 2065.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1445.7395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 20GX6 405211",
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        {
          "code": "3526416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 46.1518,
          "maximum": 486.5875,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 68.5786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL 7 SP-78107",
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        {
          "code": "3526419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1023,
          "minimum": 349.7278,
          "maximum": 742.3911,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 519.6738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-GEN VASCULAR DYNJ60177",
      "code_information": [
        {
          "code": "3526422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1556,
          "minimum": 531.9417,
          "maximum": 1129.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 790.4324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC SIE DYNJ905699",
      "code_information": [
        {
          "code": "3526423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1952,
          "minimum": 667.3202,
          "maximum": 1416.5664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 991.5965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO SHOULDER DYNJ60141",
      "code_information": [
        {
          "code": "3526425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 767,
          "minimum": 262.2103,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 389.6283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO KNEE DYNJ60140",
      "code_information": [
        {
          "code": "3526428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 209.905,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 311.9059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-LOW FLOW,DISP PATIENT",
      "code_information": [
        {
          "code": "3526443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 509.514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HIGH FLOW, DISP PT'",
      "code_information": [
        {
          "code": "3526445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1053,
          "minimum": 35.0343,
          "maximum": 764.1621,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 534.9135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SMALL PED NASAL OXYGEN",
      "code_information": [
        {
          "code": "3526446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 45.7191,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.0034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-PED/ADULT SM – MP1500",
      "code_information": [
        {
          "code": "3526447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 45.7191,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.0034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIGH FLOW ADULT MA1700",
      "code_information": [
        {
          "code": "3526449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 11710.9099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INFANT OVER THE EAR",
      "code_information": [
        {
          "code": "3526455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 121.7859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.1472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORPEDO-4.0MM X13 CM AR-8400T",
      "code_information": [
        {
          "code": "3526458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 930,
          "minimum": 317.9343,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 472.4307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ABLATOR-ASPIRATING AR-8921",
      "code_information": [
        {
          "code": "3526459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 99.5419,
          "maximum": 985.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 689.8504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR COLD 10MM Rnd",
      "code_information": [
        {
          "code": "3526467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 281,
          "minimum": 96.064,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.7452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-OVAL FLUSH-CUT AR-8550FOS",
      "code_information": [
        {
          "code": "3526471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 400.2961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOLVE-CUT RESIST XL520036000",
      "code_information": [
        {
          "code": "3526473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 281.6966,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 418.5838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE/BLACK 1.5MM",
      "code_information": [
        {
          "code": "3526474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.6796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-90 DEG APOLLO AR-9811",
      "code_information": [
        {
          "code": "3526476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 985.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 689.8504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELITE IRRIG 5407010470",
      "code_information": [
        {
          "code": "3526484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 394.2002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 12 DPSB 60707010200",
      "code_information": [
        {
          "code": "3526492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.7612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPSB 60707010300",
      "code_information": [
        {
          "code": "3526493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.0009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPSB 60707010400",
      "code_information": [
        {
          "code": "3526494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 260.8109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.7805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPDB 60708010300",
      "code_information": [
        {
          "code": "3526495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 340.3533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.2473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 260715",
      "code_information": [
        {
          "code": "3526503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.5593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TUBING MXB-T",
      "code_information": [
        {
          "code": "3526520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 506,
          "minimum": 172.9836,
          "maximum": 1638.8267,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.0429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-FLOTRAX PERFUSION 84\\\" M",
      "code_information": [
        {
          "code": "3526525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2947,
          "minimum": 497.7095,
          "maximum": 2138.6379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1497.0465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT YG-272T",
      "code_information": [
        {
          "code": "3526528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 1475.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.5MMX13CM AR-8550EX",
      "code_information": [
        {
          "code": "3526571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 230.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BULLET CUTTING 3MM",
      "code_information": [
        {
          "code": "3526591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2519,
          "minimum": 861.1576,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1279.6268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MAJOR HEAD/NEC DYNJ38985A",
      "code_information": [
        {
          "code": "3526665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 696,
          "minimum": 237.9379,
          "maximum": 1426.9526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 353.561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-BIOPATCH CHG 1”X4MM 4150",
      "code_information": [
        {
          "code": "3526904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 10956.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-JAW TISSUE ENSEAL LRG",
      "code_information": [
        {
          "code": "3526926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2829,
          "minimum": 967.1357,
          "maximum": 3864.895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1437.1037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT SMALL",
      "code_information": [
        {
          "code": "3526929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 571,
          "minimum": 195.2048,
          "maximum": 414.3747,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 290.0623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT LARGE",
      "code_information": [
        {
          "code": "3526930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 660,
          "minimum": 225.6308,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 335.2734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A443",
      "code_information": [
        {
          "code": "3526935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 393,
          "minimum": 134.3529,
          "maximum": 285.2001,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 199.6401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A445",
      "code_information": [
        {
          "code": "3526936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.1001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFX 2-0 SXMP1B413",
      "code_information": [
        {
          "code": "3526938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 352,
          "minimum": 120.3364,
          "maximum": 336.9966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.8125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4FUSION 2.0 CALIBRATED",
      "code_information": [
        {
          "code": "3526943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1113,
          "minimum": 380.4956,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 565.3929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-AFFINITY MANIFOLD 1S85R1",
      "code_information": [
        {
          "code": "3526965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COMP SPEEDARC 11X15X13MM",
      "code_information": [
        {
          "code": "3526978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5134,
          "minimum": 1755.1342,
          "maximum": 3725.7438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2608.0207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7.5CM POST",
      "code_information": [
        {
          "code": "3526995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 608,
          "minimum": 207.8538,
          "maximum": 1044.9119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 308.8579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING DISP EXT 5450850003",
      "code_information": [
        {
          "code": "3526996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1879,
          "minimum": 233.0059,
          "maximum": 1363.5903,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 954.5132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINDER-DISP SUCT CAN",
      "code_information": [
        {
          "code": "3526997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 419,
          "minimum": 143.2414,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.8478,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIAMETER-STRAIGHT 5450800309",
      "code_information": [
        {
          "code": "3526999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3756,
          "minimum": 1284.0444,
          "maximum": 2725.7292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1908.0104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRICOTHYROIDOTOMY EMERGENT",
      "code_information": [
        {
          "code": "3527020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1028,
          "minimum": 310.3038,
          "maximum": 746.0196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 522.2137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-2.7MM 311.26",
      "code_information": [
        {
          "code": "3527056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 864,
          "minimum": 295.3712,
          "maximum": 627.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 438.9034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.15, 1.5MM",
      "code_information": [
        {
          "code": "3527057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 283.0641,
          "maximum": 600.8796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 420.6157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.19, 2.0MM",
      "code_information": [
        {
          "code": "3527058",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 849,
          "minimum": 290.2433,
          "maximum": 1353.5474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 431.2835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.35X50X101MM",
      "code_information": [
        {
          "code": "3527084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 2087.0433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 526.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PICK-VEIN 6541",
      "code_information": [
        {
          "code": "3527102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 113.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.0/2.3",
      "code_information": [
        {
          "code": "3527119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1520,
          "minimum": 519.6346,
          "maximum": 1103.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 772.1448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO",
      "code_information": [
        {
          "code": "3527121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 53.9417,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 526.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BRUSH ALGER 0.5MM",
      "code_information": [
        {
          "code": "3527123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOPATCH-DRESS CHG 1” X 7MM",
      "code_information": [
        {
          "code": "3527124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 2416.2545,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLENOID DRILL 2.5MM",
      "code_information": [
        {
          "code": "3527142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8074,
          "minimum": 2760.2169,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4101.5113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD WIDE MT-APUW",
      "code_information": [
        {
          "code": "3527145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 236.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLUS-VIVAER ARC DISP CAT500",
      "code_information": [
        {
          "code": "3527147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9026,
          "minimum": 870.8526,
          "maximum": 6550.1682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4585.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-KEITH FREE 1827-2.5DC",
      "code_information": [
        {
          "code": "3527159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3MM AR-8930D-13",
      "code_information": [
        {
          "code": "3527163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 83.415,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-GONIO SURG OSIG",
      "code_information": [
        {
          "code": "3527169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 4705.7182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO V4608-20",
      "code_information": [
        {
          "code": "3527175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 104,
          "minimum": 35.5539,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 3.2X125MM GRAY",
      "code_information": [
        {
          "code": "3527179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1195,
          "minimum": 408.5285,
          "maximum": 1627.1486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 607.048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-POSEY SECURE INFANT PED",
      "code_information": [
        {
          "code": "3527200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 389,
          "minimum": 132.9854,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.6081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-INDIGO 140CM CATRXKIT",
      "code_information": [
        {
          "code": "3527201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8123,
          "minimum": 2588.0894,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4126.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPERATOR-C4 PENUMBRA SEPC4",
      "code_information": [
        {
          "code": "3527202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4654,
          "minimum": 1343.5376,
          "maximum": 3377.4078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2364.1855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENGINE INDIGO IAPS3",
      "code_information": [
        {
          "code": "3527203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 259.1426,
          "maximum": 1753.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1227.3038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRVO2-TUBE CHAMBER KIT, 900PT",
      "code_information": [
        {
          "code": "3527205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 730,
          "minimum": 249.5613,
          "maximum": 5082.1979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 370.8327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN W/AO 5.0MM",
      "code_information": [
        {
          "code": "3527232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 9536.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 247.8991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-QUICK CONN DRVR-UQC-T10",
      "code_information": [
        {
          "code": "3527241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1399,
          "minimum": 478.2689,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 710.678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7X70MM IJS-CDC-2770",
      "code_information": [
        {
          "code": "3527242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2785,
          "minimum": 952.0936,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1414.7521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSSEPTAL NTK-711-8545",
      "code_information": [
        {
          "code": "3527245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 81.1906,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERES-PASSIVE 8801075",
      "code_information": [
        {
          "code": "3527246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.1665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.9X10X61MM",
      "code_information": [
        {
          "code": "3527253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 526.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DRILL SELF HOLD",
      "code_information": [
        {
          "code": "3527257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2110,
          "minimum": 721.3349,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1071.8589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE 108984",
      "code_information": [
        {
          "code": "3527264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 284.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO MICRO 0",
      "code_information": [
        {
          "code": "3527266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 649,
          "minimum": 221.8703,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 329.6855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3527268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5424,
          "minimum": 311.9721,
          "maximum": 3936.1968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2755.3378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-STERILE PGH 396985",
      "code_information": [
        {
          "code": "3527269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 284.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-BS IS-1 330834",
      "code_information": [
        {
          "code": "3527270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 7MM, 70X",
      "code_information": [
        {
          "code": "3527281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 359.1489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-301-CG 343586",
      "code_information": [
        {
          "code": "3527282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 284.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIDER TS101DC",
      "code_information": [
        {
          "code": "3527287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 594,
          "minimum": 99.5419,
          "maximum": 431.0658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 301.7461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM 7089-0832",
      "code_information": [
        {
          "code": "3527289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.947,
          "maximum": 88.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3869,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 1.27MM",
      "code_information": [
        {
          "code": "3527290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 5375.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.2784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER DS2C026",
      "code_information": [
        {
          "code": "3527342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4316,
          "minimum": 208.5375,
          "maximum": 3132.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2192.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ALLEN 3.0MM 904-0030",
      "code_information": [
        {
          "code": "3527343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 375,
          "minimum": 128.1993,
          "maximum": 4835.2895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 190.4962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3527395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 97.9695,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.5786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAXI-THERM LITE 871*******",
      "code_information": [
        {
          "code": "3527520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.1632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-CALAZIME REMEDY 4 OZ",
      "code_information": [
        {
          "code": "3527567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-K SOFT 117464",
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        {
          "code": "3527806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 183.5814,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 60-S FIRM 119291",
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        {
          "code": "3527807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 191.7862,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-C MEDIUM 342657",
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        {
          "code": "3527808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 03.033.004",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-INFANT POSITIONER",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CRM DYNJ62070",
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        {
          "code": "3527887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 258.4498,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-INFANT FULL BODY",
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        {
          "code": "3527890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 362.0349,
          "maximum": 970.9506,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNCK SLCT980010",
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        {
          "code": "3527947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 32.4772,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-IRR SUCT 5500-573-000",
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        {
          "code": "3527977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 331.9917,
          "maximum": 2269.2639,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION 5450-851-012",
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        {
          "code": "3527978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 204.0933,
          "maximum": 2832.7734,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MICRO-IQ 12CM 5500-25S-309",
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        {
          "code": "3527979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 1741.4596,
          "maximum": 3696.7158,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STD-12CM 5500-25S-307",
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        {
          "code": "3527980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1625.2255,
          "maximum": 3449.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2414.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRACUDA-12CM IQ 5500-25S-310",
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        {
          "code": "3527981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 3774.3657,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2642.056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-APEX 11CM 5500-25B-114",
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        {
          "code": "3527983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 342.0015,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND ROYLAN RT MED",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORTHOSIS-ANKLE FOOT LG",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "minimum": 240.6729,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 30 DPSB 60707010500",
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        {
          "code": "3529495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPDB 60708010200",
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        {
          "code": "3529498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 146.3182,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SINGLE DRY SUCTION",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 217.7679,
          "maximum": 462.2709,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST DOUBLE DRY SUCTION",
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          "code": "3533159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 159.9928,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #4     4DCP",
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        {
          "code": "3533309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #6,8,10 DCP",
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        {
          "code": "3533315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 22.9049,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SKIN TEMP DISP MU11228",
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        {
          "code": "3533577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP ISOLETTE    MU12551",
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        {
          "code": "3533578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 51.1612,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 120.9016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-RECTAL/ESOPH ST     491B",
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        {
          "code": "3533590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTANT-SKIN REMEDY 2 OZ",
      "code_information": [
        {
          "code": "3536085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 21.1956,
          "maximum": 78.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 31.4954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-SKIN NO STING    MSC1528",
      "code_information": [
        {
          "code": "3536099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 142,
          "minimum": 48.5448,
          "maximum": 103.0494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.1346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-EYE FOAM       28300",
      "code_information": [
        {
          "code": "3536100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 957.0481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-JP 100ML  SU130-1305",
      "code_information": [
        {
          "code": "3538200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3539345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 197.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INITIATION BREAST MILK 673",
      "code_information": [
        {
          "code": "3539346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 356,
          "minimum": 111.22,
          "maximum": 258.3492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 180.8444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-BIS QUATTRO    186-0106",
      "code_information": [
        {
          "code": "3541300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 336,
          "minimum": 114.8666,
          "maximum": 243.8352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 170.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS PED DISP",
      "code_information": [
        {
          "code": "3541324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS ADLT DISP",
      "code_information": [
        {
          "code": "3541325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SKIN HNICU38",
      "code_information": [
        {
          "code": "3541328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 187.4057,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.4315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RECIP PLATELET     4C-2100",
      "code_information": [
        {
          "code": "3541430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 116.112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.2784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD FILTRATION   4020005",
      "code_information": [
        {
          "code": "3541446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 140.1372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.1825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BURETROL 150ML",
      "code_information": [
        {
          "code": "3541503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 252,
          "minimum": 86.1499,
          "maximum": 2947.8861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 128.0135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW RADIAL ARTERY",
      "code_information": [
        {
          "code": "3541912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.8183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP Y FOR BLOOD IV  D-100",
      "code_information": [
        {
          "code": "3541945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 162.3812,
          "maximum": 618.2964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 432.8075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DIALYZER EXELTRA    5M2119",
      "code_information": [
        {
          "code": "3541947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 292,
          "minimum": 99.8245,
          "maximum": 855.8379,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 148.3331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3541950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1539,
          "minimum": 365.3577,
          "maximum": 1116.8523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 781.7966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FEMORAL ART  C-PMS-401J-FA",
      "code_information": [
        {
          "code": "3542127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 828.0329,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO ALL SZ W/ STABILIZER",
      "code_information": [
        {
          "code": "3542128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1489,
          "minimum": 509.0368,
          "maximum": 1250.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 756.3971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER HF 1000 PRISMAFLEX",
      "code_information": [
        {
          "code": "3542131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2248,
          "minimum": 99.5419,
          "maximum": 1631.3736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1141.9615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 110 INFUSION 1635101",
      "code_information": [
        {
          "code": "3542760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 1262.9031,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.0387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRISMAFLEX TPE2000 114093",
      "code_information": [
        {
          "code": "3542806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2271,
          "minimum": 99.5419,
          "maximum": 1648.0647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1153.6453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RADIAL ARTERY C-PMS-301-RA",
      "code_information": [
        {
          "code": "3543008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 61.171,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORACENTESIS      4653-48",
      "code_information": [
        {
          "code": "3543530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TUR IRRIGATION  06543-01",
      "code_information": [
        {
          "code": "3543551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 596.6953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE XL REPOSITION",
      "code_information": [
        {
          "code": "3543685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 38.3709,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 402.3281,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE SM   2042-01",
      "code_information": [
        {
          "code": "3543730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 126.7908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE LRG  2042-03",
      "code_information": [
        {
          "code": "3543732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 63.9515,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-NIPPLE REGULAR   67203S",
      "code_information": [
        {
          "code": "3544003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 92.3126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SEQ COMP KNEE      95xx",
      "code_information": [
        {
          "code": "3544619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 150.9456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.6619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501B",
      "code_information": [
        {
          "code": "3544638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.6459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501L",
      "code_information": [
        {
          "code": "3544639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 167,
          "minimum": 57.0914,
          "maximum": 121.1919,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE   VP501M",
      "code_information": [
        {
          "code": "3544640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 114.5566,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 75.1825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530M",
      "code_information": [
        {
          "code": "3544645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.6459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530L",
      "code_information": [
        {
          "code": "3544650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 31.6977,
          "maximum": 164.0082,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 114.8057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM CHILD        8001-01",
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        {
          "code": "3544659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 19.4863,
          "maximum": 41.3649,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 28.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ELEVATOR     8011-02",
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        {
          "code": "3544860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE ALL SZS TX4442-0x",
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        {
          "code": "3545160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 43.7587,
          "maximum": 92.8896,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE PED       9007-00",
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        {
          "code": "3545177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 48.2029,
          "maximum": 299.7379,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 3L   5B9858",
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        {
          "code": "3545500",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 184.2652,
          "maximum": 391.1523,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 3L  5B9859",
      "code_information": [
        {
          "code": "3545502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 190.4187,
          "maximum": 404.2149,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 2L  5B9896",
      "code_information": [
        {
          "code": "3545504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 2L   5B9876",
      "code_information": [
        {
          "code": "3545505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIAL 1.5% 3L       5B9857",
      "code_information": [
        {
          "code": "3545515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 32.2538,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 1000ML  07139-09",
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        {
          "code": "3545555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 2000ML  07973-07",
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        {
          "code": "3545613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 73.8428,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-GYLCINE 1.5% IRRIG 3000ML",
      "code_information": [
        {
          "code": "3545747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 70.4242,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML  07972-08",
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        {
          "code": "3545751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 3000ML 07828-08",
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        {
          "code": "3545752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 35.5904,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML R5200-01",
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        {
          "code": "3545753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 21.8794,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 1000ML 07953-09",
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        {
          "code": "3545755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "code": "3545852",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 18.4607,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-MDI ADAPTER INLINE",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "TAP-4.0MM 2883-02-040",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1735.6479,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "TEMPLATE-BENDING 03.501.072",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 352.8045,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 650.010",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 204.0933,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM 60XL",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 231.1006,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 343.4012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIXER-CEMENT 3CC 658.969S",
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        {
          "code": "3547948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.601S",
      "code_information": [
        {
          "code": "3547949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1534.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ULTRA ACCESS 658.902S",
      "code_information": [
        {
          "code": "3547952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5359,
          "minimum": 696.7933,
          "maximum": 3889.0263,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2722.3184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC M6275009/10",
      "code_information": [
        {
          "code": "3547958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.9748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-QUILL 2-0 YA-2034Q",
      "code_information": [
        {
          "code": "3547961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 336,
          "minimum": 114.8666,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 170.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-4-0 PROLENE 8526H",
      "code_information": [
        {
          "code": "3547969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 375.9236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.7191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT",
      "code_information": [
        {
          "code": "3547970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 221.3278,
          "maximum": 490.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 343.4012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX",
      "code_information": [
        {
          "code": "3547971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 398,
          "minimum": 136.0622,
          "maximum": 320.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 202.18,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY UNCUFF",
      "code_information": [
        {
          "code": "3547972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 292.6022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 2MM AR-7523",
      "code_information": [
        {
          "code": "3547986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-ZONE NAVIGATOR AR-7900",
      "code_information": [
        {
          "code": "3547987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 207.4253,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 650.112",
      "code_information": [
        {
          "code": "3547990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2992.9302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX CN",
      "code_information": [
        {
          "code": "3547997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 354.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 247.8991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX UN",
      "code_information": [
        {
          "code": "3547998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 402,
          "minimum": 31.1416,
          "maximum": 291.7314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 204.212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SHILEY",
      "code_information": [
        {
          "code": "3547999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 373.1431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY CUFFED",
      "code_information": [
        {
          "code": "3548000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 671,
          "minimum": 229.3913,
          "maximum": 486.9447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 340.8613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED  4LPC",
      "code_information": [
        {
          "code": "3548001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 626,
          "minimum": 67.2881,
          "maximum": 454.2882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 318.0017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ4 S",
      "code_information": [
        {
          "code": "3548003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 121,
          "minimum": 37.2587,
          "maximum": 87.8097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.4668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-TRACH 15MM DECANN WHITE",
      "code_information": [
        {
          "code": "3548004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-TRACH SZ 1 DECANN SH",
      "code_information": [
        {
          "code": "3548005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 433.758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.9394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED",
      "code_information": [
        {
          "code": "3548006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 780,
          "minimum": 31.1416,
          "maximum": 566.046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 396.2322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY FLEX INNER",
      "code_information": [
        {
          "code": "3548007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 56,
          "minimum": 19.1444,
          "maximum": 67.2881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FLUENT DISP FLT-112",
      "code_information": [
        {
          "code": "3548028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1739,
          "minimum": 594.503,
          "maximum": 1638.8267,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 883.3946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRESSING CHANGE 76681",
      "code_information": [
        {
          "code": "3549001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 275,
          "minimum": 94.0128,
          "maximum": 279.1622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 139.6972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEELIFT-AFO  081531532",
      "code_information": [
        {
          "code": "3549018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 842,
          "minimum": 287.8502,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 427.7276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-SUCTION NEURO NST031/25",
      "code_information": [
        {
          "code": "3549020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-SHANK MOD 5",
      "code_information": [
        {
          "code": "3549027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1534.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-LORDOTIC 5",
      "code_information": [
        {
          "code": "3549030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 15838.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1193.2685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KVLAB3C",
      "code_information": [
        {
          "code": "3549037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 116.8377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.7864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPEN 279726500",
      "code_information": [
        {
          "code": "3549047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3029,
          "minimum": 1035.5087,
          "maximum": 2198.1453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1538.7017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX ER VALVE REPLACEMEN",
      "code_information": [
        {
          "code": "3549059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 180.7325,
          "maximum": 407.1177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 284.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX CATH ACCESS 50-7280",
      "code_information": [
        {
          "code": "3549060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-NAVIGATION 286750210S",
      "code_information": [
        {
          "code": "3549063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1363.9531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 020 XFR004xxx",
      "code_information": [
        {
          "code": "3549066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2903,
          "minimum": 992.4337,
          "maximum": 2273.3368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1474.695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL SND1T3 20.5",
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        {
          "code": "3549069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5049,
          "minimum": 1726.0757,
          "maximum": 3664.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2564.8415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-SYNC DISTAL RADIAL, SDRB-",
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        {
          "code": "3549082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 206.2439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-FEMORAL AUG SZ6 154906002",
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        {
          "code": "3549097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- LIGHT 03.612.021S",
      "code_information": [
        {
          "code": "3549135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2191,
          "minimum": 749.0259,
          "maximum": 1590.0087,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1113.0061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LIGHT 03.615.132S",
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        {
          "code": "3549136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1748,
          "minimum": 597.5798,
          "maximum": 1268.5236,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 887.9665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 388.175",
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        {
          "code": "3549150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1078,
          "minimum": 368.5303,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 547.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 9-0 V449G",
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        {
          "code": "3549155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 111.7578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHALANGEAL 20MM",
      "code_information": [
        {
          "code": "3549160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 1032.4319,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1534.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADER-TRIAL DRG 7032ANS",
      "code_information": [
        {
          "code": "3549166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1363.9531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL PRP ABS-10061T",
      "code_information": [
        {
          "code": "3549185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1107.9262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.021S",
      "code_information": [
        {
          "code": "3549190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2362,
          "minimum": 807.4848,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1199.8724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703713",
      "code_information": [
        {
          "code": "3549201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 859.5191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TAP 12.5MM 338.17",
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        {
          "code": "3549204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1357.8573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- CANN 6.5MM 702603",
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        {
          "code": "3549216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2032,
          "minimum": 580.0123,
          "maximum": 1474.6224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1032.2357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CSG WORLEY STANDARD",
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        {
          "code": "3549218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1900,
          "minimum": 649.5432,
          "maximum": 1378.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 965.181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-UNCUFFED 7.0 70XLTUP",
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        {
          "code": "3549227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 231.1006,
          "maximum": 1146.6782,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 343.4012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.1X87 A-3836",
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        {
          "code": "3549229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CROSS PLATE 705172",
      "code_information": [
        {
          "code": "3549243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2762,
          "minimum": 944.2307,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1403.0684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL CPRP ABS-10063",
      "code_information": [
        {
          "code": "3549250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1980,
          "minimum": 676.8924,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1005.8202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-THREAD LOCK 03.835.009S",
      "code_information": [
        {
          "code": "3549252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1698,
          "minimum": 491.0363,
          "maximum": 1232.2386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 862.567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPEEDGUIDE-T8 2.4/2.7X30MM",
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        {
          "code": "3549269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2408,
          "minimum": 823.2106,
          "maximum": 3101.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1223.2399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEEDGUIDE AO 2.0X30MM",
      "code_information": [
        {
          "code": "3549270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5577,
          "minimum": 249.1328,
          "maximum": 4047.2289,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2833.0602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 2.1MM",
      "code_information": [
        {
          "code": "3549272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1742,
          "minimum": 595.5286,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 884.9186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS TRIPLE 91429",
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        {
          "code": "3549278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 453,
          "minimum": 154.8648,
          "maximum": 1347.4303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 230.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.1X300MM RMT3130",
      "code_information": [
        {
          "code": "3549279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2423,
          "minimum": 575.0074,
          "maximum": 1758.3711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1230.8598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-2.5 SOLID HT-2502",
      "code_information": [
        {
          "code": "3549283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 71.1808,
          "maximum": 1091.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 764.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-DHS REAMER 338.13",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1455.3137,
          "maximum": 5311.3983,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3717.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-PALM ROLYAN SOFT GEL LT",
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        {
          "code": "3549295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 246,
          "minimum": 84.0988,
          "maximum": 178.5222,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 124.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FORCEP SUCTION 9G12R",
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        {
          "code": "3549304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 6512.4871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CATH LINE 020378801",
      "code_information": [
        {
          "code": "3549311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 3739.2164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM 6149.1035",
      "code_information": [
        {
          "code": "3549338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 265.8158,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 650.114",
      "code_information": [
        {
          "code": "3549348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ANGLE 14MM 684.434",
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        {
          "code": "3549349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1534.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 16MM 650.116",
      "code_information": [
        {
          "code": "3549372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 446.1336,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 662.9269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP 2.4MM",
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        {
          "code": "3549451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 112.4735,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 167.1287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB LARGE AR-8970-09",
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        {
          "code": "3549452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 482.0295,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 716.2659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ADAPTER BIOPSY MAJ-1414",
      "code_information": [
        {
          "code": "3549507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 35676.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.4987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-THUMB SPICA ANY    350S",
      "code_information": [
        {
          "code": "3549700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 578.9001,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.0387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUICKCLOT 8X8 4010",
      "code_information": [
        {
          "code": "3549703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 528.8176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-COMFY FINGER",
      "code_information": [
        {
          "code": "3549716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 405.3969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 6 6SIC",
      "code_information": [
        {
          "code": "3549725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 89.2611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.4828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 8 8SIC",
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        {
          "code": "3549726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 42.0494,
          "maximum": 14374.0728,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 62.4828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUIKCLOT 5X5 4000",
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        {
          "code": "3549730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 733,
          "minimum": 250.5869,
          "maximum": 531.9381,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOCN0346",
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        {
          "code": "3549731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 261.5266,
          "maximum": 1829.0129,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 388.6123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 200 AC-10030100",
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        {
          "code": "3549732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3289,
          "minimum": 7.7854,
          "maximum": 2386.8273,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1670.7791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ESOPHAGEAL 100001",
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        {
          "code": "3549734",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 337.5527,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1346.6815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BV175-6 BLUE EPM8743",
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        {
          "code": "3549735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 607,
          "minimum": 207.512,
          "maximum": 1436.9624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 308.3499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 365 AC-10030110",
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        {
          "code": "3549736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1312.6462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LONG TUNNELING SC-4254",
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        {
          "code": "3549742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 2490.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1023.0919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM 03.010.061",
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        {
          "code": "3549747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1751,
          "minimum": 598.6054,
          "maximum": 2885.6029,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 889.4905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 16MM 03.037.002",
      "code_information": [
        {
          "code": "3549748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5189,
          "minimum": 1773.9368,
          "maximum": 3765.6573,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2635.9601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 6-9MM 03.037.022",
      "code_information": [
        {
          "code": "3549750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3479,
          "minimum": 112.3322,
          "maximum": 2524.7103,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1767.2972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-BABYFLOW PLUS S DISP MP37",
      "code_information": [
        {
          "code": "3549751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-DISP",
      "code_information": [
        {
          "code": "3549752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 178,
          "minimum": 60.8519,
          "maximum": 129.1746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEOMASK-CPAP",
      "code_information": [
        {
          "code": "3549753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 142.2372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BABUFLOE SZ 4 DISP MP0149",
      "code_information": [
        {
          "code": "3549754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 225,
          "minimum": 76.9196,
          "maximum": 163.2825,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.2977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP",
      "code_information": [
        {
          "code": "3549755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.4382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PNEUMOTHORAX G05297",
      "code_information": [
        {
          "code": "3549757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1013,
          "minimum": 200.196,
          "maximum": 735.1341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 514.5939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOURNIQUET-TACTICAL 30-0023",
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        {
          "code": "3549759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 360,
          "minimum": 123.0713,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 182.8764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R001",
      "code_information": [
        {
          "code": "3549765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 1875.2088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1312.6462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-A003",
      "code_information": [
        {
          "code": "3549766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 601.7002,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1619.4721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-SEATTLE PLUS MP02260",
      "code_information": [
        {
          "code": "3549776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 99.5419,
          "maximum": 409.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 286.5064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-DISTAL 24MM 03.211.024",
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        {
          "code": "3549786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 902.5232,
          "maximum": 1915.848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1341.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PROX 24MM 03.211.124",
      "code_information": [
        {
          "code": "3549787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 902.5232,
          "maximum": 3736.4359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1341.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROCESSOR-SOUND LINE 90711",
      "code_information": [
        {
          "code": "3549810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 141.2494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-BAHA STORAGE Z342010",
      "code_information": [
        {
          "code": "3549811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 2902.2859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.0295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-PERFORM REV PERI MWJ126",
      "code_information": [
        {
          "code": "3549818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 509.514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5X220MM DWD017",
      "code_information": [
        {
          "code": "3549819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 950,
          "minimum": 324.7716,
          "maximum": 3199.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 482.5905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SHAFT 8X510 0227-8510S",
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        {
          "code": "3549851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1867,
          "minimum": 638.2617,
          "maximum": 2859.4662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 948.4173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LOCKING 705078",
      "code_information": [
        {
          "code": "3549854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1563,
          "minimum": 534.3348,
          "maximum": 1251.7811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 793.9884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 700354",
      "code_information": [
        {
          "code": "3549867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1228,
          "minimum": 419.81,
          "maximum": 891.1596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 623.8117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW INFINITY 3600315",
      "code_information": [
        {
          "code": "3549870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 2635.3579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 636.5115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.4 G3606010",
      "code_information": [
        {
          "code": "3549873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 2635.3579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 363.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-STRAIGH TIP 2762-01-0004",
      "code_information": [
        {
          "code": "3549916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 1078.5836,
          "maximum": 9858.5408,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1602.7084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR NIM 945NSD2750",
      "code_information": [
        {
          "code": "3549918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 10600.3782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1687.5428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAGITTAL 2296-003-155",
      "code_information": [
        {
          "code": "3549927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 417.6311,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.1001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 2.4 1608-006-147",
      "code_information": [
        {
          "code": "3549928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 751,
          "minimum": 256.7405,
          "maximum": 545.0007,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 381.5005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 1MM 1608-006-151",
      "code_information": [
        {
          "code": "3549929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 722,
          "minimum": 207.4253,
          "maximum": 523.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.7688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-413S1",
      "code_information": [
        {
          "code": "3549931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 289.7281,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.1001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 7X15MM 2296-003-103",
      "code_information": [
        {
          "code": "3549932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 178.1116,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 264.6628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-111S5",
      "code_information": [
        {
          "code": "3549933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 281.5716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.1001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHORT 2.5MM 2296-003-413",
      "code_information": [
        {
          "code": "3549934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 501,
          "minimum": 125.6786,
          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 254.503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48X70MM 2108-197-00S4",
      "code_information": [
        {
          "code": "3549935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 77.2615,
          "maximum": 409.8457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X75MM 4125-089-075",
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        {
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          "type": "LOCAL"
        },
        {
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          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90 4125-097-090",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 204.7771,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "3549938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "BLADE-SAG 25X90MM 4125-119-090",
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        },
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        }
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        {
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            }
          ]
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      ],
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    {
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        {
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            }
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-70X12.5MM 0277-096-277",
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        },
        {
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        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RECIPR. 0277-096-325",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
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        }
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-18.5X90.5 2108-382-003",
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        },
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          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE,SAW VASC 5400-134-415",
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          "type": "LOCAL"
        },
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          "code": "0270",
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        }
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE, SAW 25X90MM 6725-127-09",
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        },
        {
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          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 8MM M0013635",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SPINAL W/EPI & BUPIV 3338",
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        },
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        }
      ],
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        {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
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          "type": "RC"
        }
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SUTURE UCL AR-7715-4.5",
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        },
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          "type": "RC"
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        {
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          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
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        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-TIB 42-5320-064-02",
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        {
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      ],
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        {
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            {
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            }
          ]
        }
      ],
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    },
    {
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
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            }
          ]
        }
      ],
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    },
    {
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        {
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        }
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            }
          ]
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    {
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      ],
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          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL 4-0 18\\\" PC-3",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 22.9049,
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            {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROS-NASAL SEPTAL ROUND SP1102",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 631.0825,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.007.01S",
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        {
          "code": "0270",
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        {
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    {
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        {
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        {
          "code": "0270",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP REG 47700100",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 585.2726,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP SLIM 4760010",
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        {
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        {
          "code": "0270",
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      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "BIT-DRILL CAN 190MM 03.010.036",
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        {
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        {
          "code": "0270",
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        {
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          ]
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      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "0270",
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        {
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          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-ANNULOTOMY 675.405S",
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        {
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        {
          "code": "0270",
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        {
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    {
      "description": "DISC-SHIM SS 6133.0326S",
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        {
          "code": "0270",
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        {
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            {
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      "service_type": "CDM"
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    {
      "description": "PACK-FILLER DELIVERY 658.914S",
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        {
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        {
          "code": "0270",
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        {
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            {
              "payer_name": "Anthem",
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      "service_type": "CDM"
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    {
      "description": "BIT-DRILL CT 3.5M 6149.9135",
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        {
          "code": "3550137",
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        },
        {
          "code": "0270",
          "type": "RC"
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIABETIC FOOT CARE 0811748",
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        {
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 75.2103,
          "maximum": 159.654,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 71MM 705506",
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        {
          "code": "3550158",
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        {
          "code": "0270",
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
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      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT RSZ4001S",
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        {
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        {
          "code": "0270",
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        {
          "setting": "inpatient",
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          "minimum": 676.8924,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
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      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW 1020-00-000",
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        {
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        {
          "code": "0270",
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      "standard_charges": [
        {
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          "minimum": 175.3767,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
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      "service_type": "CDM"
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    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-C001",
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 482.0295,
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            {
              "payer_name": "Anthem",
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            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22GX9CM",
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        {
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        {
          "code": "0270",
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        {
          "setting": "inpatient",
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          "minimum": 138.7971,
          "maximum": 10649.315,
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            {
              "payer_name": "Anthem",
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      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.8X122 A-3738",
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        {
          "code": "0270",
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        {
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          "minimum": 789.366,
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            {
              "payer_name": "Anthem",
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    },
    {
      "description": "NEEDLE-EPIMED RX COUDE 1314ANS",
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        {
          "code": "0270",
          "type": "RC"
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        {
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          "minimum": 244.7752,
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            {
              "payer_name": "Anthem",
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            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "DISC-CERV MOBI-C 13X17 MB3375",
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        },
        {
          "code": "0270",
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        {
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            {
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPAR 14MM 0024-LDR",
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        {
          "code": "0270",
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      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYGEN VOCSN PRT-00930",
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        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE 2.5MM 694",
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        {
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        },
        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
            {
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          ]
        }
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      "service_type": "CDM"
    },
    {
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        },
        {
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      ],
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        {
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          ]
        }
      ],
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    },
    {
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        {
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      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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      ],
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        {
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            {
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INSERTER 694.004",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-INSERTER 694.005",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-CALIBER GRAPHIC 994.001",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4842.8576,
          "maximum": 22391.3665,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARGYLE SHUNT 8888577775",
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        {
          "code": "3550249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 142.5576,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 211.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND A31216",
      "code_information": [
        {
          "code": "3550250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 93.4248,
          "maximum": 361.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 252.979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-MEPITEL 6.8X10",
      "code_information": [
        {
          "code": "3550253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 186.8496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.0261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 12FR 1.0CM",
      "code_information": [
        {
          "code": "3550256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 3921.0611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 488.1784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-I/A CAPSULGUARD",
      "code_information": [
        {
          "code": "3550264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 135.6333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE RT SM 70831",
      "code_information": [
        {
          "code": "3550272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 338,
          "minimum": 115.5503,
          "maximum": 245.2866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 171.7006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE LT SM 70831",
      "code_information": [
        {
          "code": "3550273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 121.0202,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 179.8285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-OSTEOFUZE OF-BMA-11",
      "code_information": [
        {
          "code": "3550274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8800,
          "minimum": 483.807,
          "maximum": 6386.16,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4470.312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET REUSE",
      "code_information": [
        {
          "code": "3550275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 870,
          "minimum": 80.6345,
          "maximum": 631.359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 441.9513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-HEMOSTATIC POWDER 1978",
      "code_information": [
        {
          "code": "3550278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 10602.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 375.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R002",
      "code_information": [
        {
          "code": "3550306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2584,
          "minimum": 883.3788,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1312.6462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TROCAR THORACIC 24FR SWD",
      "code_information": [
        {
          "code": "3550314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 110.7642,
          "maximum": 477.6899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-INSPIRA BREAST SRM",
      "code_information": [
        {
          "code": "3550331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4485,
          "minimum": 232.4498,
          "maximum": 3254.7645,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2278.3351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DEFENDO Y-OPSY 100303",
      "code_information": [
        {
          "code": "3550394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 640.0711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PUSHLOCK 2.9MM",
      "code_information": [
        {
          "code": "3550395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1151,
          "minimum": 393.4865,
          "maximum": 835.2807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 584.6965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM",
      "code_information": [
        {
          "code": "3550396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 689.8504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH 8MM 100/897/080",
      "code_information": [
        {
          "code": "3550399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 878,
          "minimum": 75.6296,
          "maximum": 637.1646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 446.0152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER 8MM 100/890/080",
      "code_information": [
        {
          "code": "3550400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 18FR 897518",
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        {
          "code": "3550406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 195,
          "minimum": 66.6636,
          "maximum": 141.5115,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-TRIPLE NEEDLE INS-5300",
      "code_information": [
        {
          "code": "3550411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4172,
          "minimum": 1426.2602,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2119.3343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPIN W/ADAPTER INS-5910",
      "code_information": [
        {
          "code": "3550414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4906,
          "minimum": 207.4253,
          "maximum": 3560.2842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2492.1989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J556G",
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        {
          "code": "3550419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 132.8031,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.9622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0 770G",
      "code_information": [
        {
          "code": "3550420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 52.8295,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 101.598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8695G",
      "code_information": [
        {
          "code": "3550421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 6549.7458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-REDDIE KNEE XL 08154723",
      "code_information": [
        {
          "code": "3550426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 437,
          "minimum": 148.4787,
          "maximum": 317.1309,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 221.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-BACK ROLYANFIT MESH",
      "code_information": [
        {
          "code": "3550427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 46414.3304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 135.6333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-2.3MM PED SCREW 4008-00",
      "code_information": [
        {
          "code": "3550429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 811.906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING RS5200",
      "code_information": [
        {
          "code": "3550447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5472,
          "minimum": 325.3185,
          "maximum": 3971.0304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2779.7213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-FIXATION LG FP9000L",
      "code_information": [
        {
          "code": "3550448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 36889.4496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 297.1741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-PRIME 286750200S",
      "code_information": [
        {
          "code": "3550473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 9520.9881,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1363.9531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-MMG 2862-02-108",
      "code_information": [
        {
          "code": "3550480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1175,
          "minimum": 401.6912,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 596.8882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 03.010.060",
      "code_information": [
        {
          "code": "3550483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1814,
          "minimum": 620.1429,
          "maximum": 7248.7635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 921.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-120",
      "code_information": [
        {
          "code": "3550487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 344.2579,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 511.5459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-120LP",
      "code_information": [
        {
          "code": "3550488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 959,
          "minimum": 327.8484,
          "maximum": 721.8178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 487.1624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MACY BEDSIDE DELIVERY M",
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        {
          "code": "3550498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 932,
          "minimum": 88.4199,
          "maximum": 676.3524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 473.4467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PRESSURE OPAQUE 50P148",
      "code_information": [
        {
          "code": "3550499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 369.8065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH,MALE EXTERNAL",
      "code_information": [
        {
          "code": "3550511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH PEDIATRIC",
      "code_information": [
        {
          "code": "3550515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.5786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO CF DEL FGS-0635",
      "code_information": [
        {
          "code": "3550530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2212,
          "minimum": 756.2051,
          "maximum": 7374.4421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1123.6739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM ST 6149.1036S",
      "code_information": [
        {
          "code": "3550541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 503.9261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF XL MDS601BD",
      "code_information": [
        {
          "code": "3550555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT MED MDS620",
      "code_information": [
        {
          "code": "3550556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 257,
          "minimum": 87.8593,
          "maximum": 186.5049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.5534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT LRG MDS620L",
      "code_information": [
        {
          "code": "3550557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 277,
          "minimum": 94.6966,
          "maximum": 201.0189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH MED MDS630MD",
      "code_information": [
        {
          "code": "3550558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 351,
          "minimum": 119.9946,
          "maximum": 254.7207,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.3045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH LRG MDS630LD",
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        {
          "code": "3550559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 184.4004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH X-LG MDS630BD",
      "code_information": [
        {
          "code": "3550560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 383,
          "minimum": 130.9342,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 194.5602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT 10° TIP MLD-0068",
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        {
          "code": "3550592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 662.3151,
          "maximum": 2289.5835,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1602.7084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.5X350MM PK6 MLD-0301",
      "code_information": [
        {
          "code": "3550593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 2744.9096,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 605.0161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-8/13/18MM MLD-0441S",
      "code_information": [
        {
          "code": "3550594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1041.5753,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2507.4386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIM-SPIKE BLUNT MLD-0513",
      "code_information": [
        {
          "code": "3550595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 640.3129,
          "maximum": 1359.2361,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 951.4653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- DILATOR MLD-0345",
      "code_information": [
        {
          "code": "3550596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 9520.9881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 605.0161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-THORACIC TGMR312610",
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        {
          "code": "3550613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84847,
          "minimum": 3513.4398,
          "maximum": 61573.4679,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43101.4275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X12MM 03.501.762",
      "code_information": [
        {
          "code": "3550619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2487,
          "minimum": 207.4253,
          "maximum": 1804.8159,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1263.3711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX16CM",
      "code_information": [
        {
          "code": "3550630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 291.0783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX16CM",
      "code_information": [
        {
          "code": "3550631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICAL SCREW 3603-00-TE",
      "code_information": [
        {
          "code": "3550634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PEDIATRIC YG-232T",
      "code_information": [
        {
          "code": "3550638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC 153509",
      "code_information": [
        {
          "code": "3550645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3ML 165810",
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        {
          "code": "3550646",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 19.1444,
          "maximum": 3519.0008,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 28.4474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-MARKING ROBOTIP INFARED",
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        {
          "code": "3550649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 473.2411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE F/MRI SQK65VS",
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        {
          "code": "3550657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 77.6033,
          "maximum": 164.7339,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 115.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE,FLEX FLEX-200-QFT",
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        {
          "code": "3550658",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 49.5704,
          "maximum": 769.6424,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 73.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE 24F 5CC 0",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 58.117,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 86.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ASSEMBLY DISP 83030-1",
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        {
          "code": "3550668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1576,
          "minimum": 538.779,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 800.5922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY 18G ANG 221251",
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        {
          "code": "3550683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 50.9379,
          "maximum": 438.2068,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 75.6905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VS-1 5FR 80CM BEACON TIP",
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        {
          "code": "3550691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 117.2596,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 174.2406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-VASC 14X7MM SBT1402D",
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        {
          "code": "3550693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 346.4503,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL DETACHMENT RH1",
      "code_information": [
        {
          "code": "3550699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 546.3,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 811.768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE D9212",
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        {
          "code": "3550703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 368.1885,
          "maximum": 4252.4967,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 547.1052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SMARTRELEASE ONYX 83030-",
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        {
          "code": "3550710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 497.7095,
          "maximum": 1428.9033,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1000.2323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM 2.3MM 2862-02-201",
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        {
          "code": "3550713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3171,
          "minimum": 1084.0535,
          "maximum": 7919.9762,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1610.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE ULTRASOUND 8’ CVC6",
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        {
          "code": "3550720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 85.8503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BONE HARVEST 03.404.000S",
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        {
          "code": "3550737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12726,
          "minimum": 870.8526,
          "maximum": 9235.2582,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 6464.6807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MENISCAL ROOT 71935068",
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        {
          "code": "3550740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5252,
          "minimum": 1795.4742,
          "maximum": 3811.3764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2667.9635,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-REAMER",
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        {
          "code": "3550752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3893,
          "minimum": 60.6149,
          "maximum": 2825.1501,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1977.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXY ADULT ETCO2 OM-2125-8",
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        {
          "code": "3550753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 55.3709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONET 188MM 1563-00",
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        {
          "code": "3550760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 688.5158,
          "maximum": 4252.4967,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1023.0919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT INTERSTIM 3560022",
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        {
          "code": "3550762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1631,
          "minimum": 557.5816,
          "maximum": 1183.6167,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 828.5317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 3MM BIT DK-300",
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        {
          "code": "3550765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2326,
          "minimum": 795.1777,
          "maximum": 4216.3502,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1181.5847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DECOMPRESSION ZZ-0056",
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        {
          "code": "3550777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,LASER TRACH",
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        {
          "code": "3550778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 183.5814,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 675.725S",
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        {
          "code": "3550783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 2776.9683,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4126.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP THR 1.35M",
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        {
          "code": "3550793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 48.3807,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0 8762H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 29.7422,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 44.1951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (15) 8800966",
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        {
          "code": "3550803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 187.4057,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (5) 8801002",
      "code_information": [
        {
          "code": "3550804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 337,
          "minimum": 115.2085,
          "maximum": 884.7551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 171.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 4.6X220 P99-110-4622",
      "code_information": [
        {
          "code": "3550805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1591,
          "minimum": 543.907,
          "maximum": 10633.7442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 808.2121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM ADJ 2862-02-200",
      "code_information": [
        {
          "code": "3550815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3171,
          "minimum": 818.5792,
          "maximum": 2301.1947,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1610.8363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.1X50 M-R 01-7141",
      "code_information": [
        {
          "code": "3550816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1472,
          "minimum": 503.2251,
          "maximum": 4615.0739,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 747.7613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL EMBOLIZATION PODH1",
      "code_information": [
        {
          "code": "3550822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 15669.2297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 AO A-8004.03",
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        {
          "code": "3550830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1879,
          "minimum": 642.3641,
          "maximum": 4742.9769,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 954.5132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 16FR PEDS 8016",
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        {
          "code": "3550842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 2791.622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.45MM SM 45303145",
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        {
          "code": "3550850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 207.4253,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAGE-12MM/8° 50/18 LUI81249",
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        {
          "code": "3550854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 19856,
          "minimum": 870.8526,
          "maximum": 14409.4992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10086.6494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-CUSTOM MED PK623984",
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        {
          "code": "3550856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52648,
          "minimum": 667.8761,
          "maximum": 38206.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 26744.6575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BAL RX DC-RYxxxxxx",
      "code_information": [
        {
          "code": "3550857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 2455.1815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-R2P MISAGO SXRxxxxxx",
      "code_information": [
        {
          "code": "3550858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4415,
          "minimum": 1028.785,
          "maximum": 3203.9655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2242.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-METACROSS BD-xxxxxxxx",
      "code_information": [
        {
          "code": "3550859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1850,
          "minimum": 632.45,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 939.7815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT F/2.16MM 3560030",
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        {
          "code": "3550864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 14240.6088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-INTERPULSE",
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        {
          "code": "3550869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.2784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-SKULL MOUNT 9735300",
      "code_information": [
        {
          "code": "3550873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1643,
          "minimum": 561.684,
          "maximum": 1192.3251,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 834.6276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16FR A3",
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        {
          "code": "3550876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 437,
          "minimum": 149.3949,
          "maximum": 37124.1238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PERFORATED FUNCTIONAL 0",
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        {
          "code": "3550898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 146.3011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-HI-SPEED 4X11 1884068HS",
      "code_information": [
        {
          "code": "3550911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2381,
          "minimum": 813.9802,
          "maximum": 1727.8917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1209.5242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PROLAPSE HEM3335",
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        {
          "code": "3550912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2317,
          "minimum": 792.1009,
          "maximum": 3664.1429,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1177.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM XT SIGTRSB60AXT",
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        {
          "code": "3550915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3076,
          "minimum": 1051.5763,
          "maximum": 2232.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1562.5772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM MT SIGTRSB60AMT",
      "code_information": [
        {
          "code": "3550916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 865.2916,
          "maximum": 1851.2607,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1295.8825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3551250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 38.3709,
          "maximum": 119.0148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PRECISE SKIN      DS-5",
      "code_information": [
        {
          "code": "3552655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 68.4003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT  STR 35R",
      "code_information": [
        {
          "code": "3552730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 36.1465,
          "maximum": 89.2611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.4828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3552731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3552732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.1472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXW35",
      "code_information": [
        {
          "code": "3552737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 333.1039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.5946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKING-COMPRESSION CUSTOM",
      "code_information": [
        {
          "code": "3553701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 5096.1004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 304.286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-BONE",
      "code_information": [
        {
          "code": "3554025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
          "gross_charge": 9164,
          "minimum": 74.5174,
          "maximum": 6650.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4655.2204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CLAVICAL ADULT ALL 3001s",
      "code_information": [
        {
          "code": "3554085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 192.9667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.0707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "3554974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 231.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.0866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3554981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 142.5576,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 211.8318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-1/2\\\"X2\\\" SMALL    1955",
      "code_information": [
        {
          "code": "3555059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 440.4312,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 176.7805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2\\\"X14\\\" LARGE     1951",
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        {
          "code": "3555109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 270.757,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 402.3281,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2 X 3 MEDIUM     1953",
      "code_information": [
        {
          "code": "3555158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 489,
          "minimum": 65.0637,
          "maximum": 354.8673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.4071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP MED  202549",
      "code_information": [
        {
          "code": "3555307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 84.9069,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP LG   202636",
      "code_information": [
        {
          "code": "3555315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 274.1573,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORIE-XLGE 202612&201352",
      "code_information": [
        {
          "code": "3555323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 493,
          "minimum": 33.366,
          "maximum": 357.7701,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 250.4391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       G121H",
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        {
          "code": "3555374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0 FS-2   636H",
      "code_information": [
        {
          "code": "3555390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 3.4186,
          "maximum": 23.9123,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 5.0799,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-DEXON           7618-41",
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        {
          "code": "3556875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 14.7002,
          "maximum": 31.2051,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0   1663H",
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        {
          "code": "3557098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 29.7537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 20.8276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
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        {
          "code": "3557628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 36.1465,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 5.0799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 6-0 P1       697G",
      "code_information": [
        {
          "code": "3557898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        698H",
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        {
          "code": "3557956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        990H",
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        {
          "code": "3558678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 8.8976,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685G",
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        {
          "code": "3558679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 16,
          "minimum": 5.4698,
          "maximum": 51.7173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 8.1278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1653-G",
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        {
          "code": "3558947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 27.2489,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1663-H",
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        {
          "code": "3558970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 16.7514,
          "maximum": 40.5953,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 24.8915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0       1667G",
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        {
          "code": "3558978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 3-0       1669H",
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        {
          "code": "3558982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 21.8794,
          "maximum": 220.7717,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 32.5114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE P99-930-2108",
      "code_information": [
        {
          "code": "3559011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3368,
          "minimum": 900.3259,
          "maximum": 2444.1576,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1710.9103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       G695G",
      "code_information": [
        {
          "code": "3559030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 36.0673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1696-G",
      "code_information": [
        {
          "code": "3559036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.6712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON           1698G",
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        {
          "code": "3559069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 28.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM MT SIGTRSB45AMT",
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        {
          "code": "3559071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2310,
          "minimum": 789.7078,
          "maximum": 2108.1751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1173.4569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-LONG 4.2MM 703545",
      "code_information": [
        {
          "code": "3559085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3448,
          "minimum": 870.8526,
          "maximum": 2502.2136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-5X100MM FIX UNVCA5STF",
      "code_information": [
        {
          "code": "3559095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 53.3309,
          "maximum": 247.4645,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 15MM ONB15STF",
      "code_information": [
        {
          "code": "3559096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 5MM ONB5STF",
      "code_information": [
        {
          "code": "3559097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 286,
          "minimum": 97.7733,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
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        {
          "code": "3559115",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 49.2285,
          "maximum": 21028.3654,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 12FR 0200-12L",
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        {
          "code": "3559117",
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 473.141,
          "maximum": 1004.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM CDH29P",
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        {
          "code": "3559120",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 497.7095,
          "maximum": 1930.362,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
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        {
          "code": "3559142",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 142.9177,
          "maximum": 1555.1751,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15MM XTHICK SIG60AXT",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 648.1758,
          "maximum": 3212.5897,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1065832",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 48.2029,
          "maximum": 351.4552,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIAMONDTOUCH IN9152",
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        {
          "code": "3559159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 216.0586,
          "maximum": 1504.2505,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN GUARD",
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        {
          "code": "3559160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 924.7444,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLLEVE-SPIN GUARD",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 581.854,
          "maximum": 1235.1414,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYDROGEL EEG",
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        {
          "code": "3559175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 18.8026,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J493H",
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        {
          "code": "3559178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 23.2468,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0 1635G",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 32.819,
          "maximum": 100.6541,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 48.767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J670G",
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        {
          "code": "3559180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP497G",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 63.245,
          "maximum": 134.2545,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 93.9781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-12MM 10*/MD 08.815.242S",
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        {
          "code": "3559197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1787.3054,
          "maximum": 16810.8405,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW-ACC BONCH AF541",
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        {
          "code": "3559228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW,STD BLUE AF541 73-112096",
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        {
          "code": "3559229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 30.0841,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM/MED/LG",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 64.6125,
          "maximum": 105398.1891,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.2MM XS 45303125",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 356.9069,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD 4033A",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X40MM 7005-3340",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 204.0933,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X60MM 7005-3360",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 10G 0306-530-000",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 219.4772,
          "maximum": 465.8994,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ TRANS 0909-400-500",
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        {
          "code": "3559261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 239.3054,
          "maximum": 1316.2887,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 1025-011-500",
      "code_information": [
        {
          "code": "3559262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 335.8844,
          "maximum": 1717.7319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CEMENT 0306-410-000",
      "code_information": [
        {
          "code": "3559263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INDIGO SEP12",
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        {
          "code": "3559264",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 1811.2177,
          "maximum": 5878.8957,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURRETTE-10G 0306-621-000",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 497.7095,
          "maximum": 2363.6049,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FLEX CUFFED",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 256.3986,
          "maximum": 2534.7038,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-FLEXIBLE 2.9MM 682.622",
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        {
          "code": "0270",
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2516H",
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        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 35.5539,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COILED 60\\\" CT 100113",
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        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 2641.475,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-GPS 3.5MM 6143.2572",
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        },
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          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1032.4319,
          "maximum": 3212.5897,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4.2X360/SM 1320-3642S",
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          "code": "0270",
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      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383593",
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          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON BLK 4-0   1854G",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 PC-1  1855G",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 27.6911,
          "maximum": 646.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER 4MM SB4000SA",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "minimum": 99.5419,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING 19F L",
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        },
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          "code": "0270",
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        }
      ],
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        {
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          "minimum": 47.5192,
          "maximum": 522.1779,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCESS 8MM",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 50.049,
          "maximum": 681.4323,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
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        },
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          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FIBERLASE CO2",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1735.6479,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0/PC-3  1865G",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT DUAL HTDRT380",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 131.9598,
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            {
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 2X315MM 703561",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "NEEDLE-VIZISNOT2 19G",
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        },
        {
          "code": "0270",
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        }
      ],
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIP 8.5X110 72200436",
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          "type": "LOCAL"
        },
        {
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.100",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "BIT-DRILL 1.0 K-WIRE",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 22X10MM 03.501.760",
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        {
          "code": "3559485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 850.2179,
          "maximum": 1804.8159,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2590S",
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        {
          "code": "3559495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 97.0896,
          "maximum": 206.0988,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2591S",
      "code_information": [
        {
          "code": "3559496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 97.0896,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM GPS 6143.2580S",
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        {
          "code": "3559499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 631.0825,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM GPS 6143.2582S",
      "code_information": [
        {
          "code": "3559500",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "inpatient",
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM GPS 6143.2584S",
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        {
          "code": "3559501",
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        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 8FR G00980",
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        {
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          "minimum": 51.9635,
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-6MM BALT 110135",
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        {
          "code": "0270",
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      ],
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        {
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          "maximum": 577.7879,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-OVASSAPIAN 85MM BD6075",
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        {
          "code": "0270",
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        {
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          "minimum": 30.0841,
          "maximum": 1653.8414,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/55 STANDARD 7607",
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        {
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          "type": "LOCAL"
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        {
          "code": "0270",
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        {
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          "minimum": 721.8178,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8013090",
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        {
          "code": "3559559",
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        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8340050",
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        {
          "code": "3559560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y3/8X3/16X3/16 10518",
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        {
          "code": "3559582",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 21.1956,
          "maximum": 6173.2661,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CABLE 323.1090",
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        {
          "code": "3559590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 644.7571,
          "maximum": 1368.6702,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 958.0691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BRAD POINT 4MM 323.010",
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        {
          "code": "3559591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2034,
          "minimum": 695.3531,
          "maximum": 9633.8764,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1033.2517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRIPLE LUMEN 5.5FR",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1240,
          "minimum": 423.9124,
          "maximum": 899.868,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 629.9076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL LUMEN 4FR",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1190,
          "minimum": 406.8192,
          "maximum": 34190.6963,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 604.5081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 4.5X15 9009-2001",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM XT SIGTRSB45AXT",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 859.4483,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/F P01-900-1902",
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        {
          "code": "3559612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 924.7444,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/M P01-900-1903",
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        {
          "code": "3559613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 924.7444,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEE-UTILIZATION PER CASE",
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        {
          "code": "3559626",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.0MM 705360",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SENSOR SPO2 1822A-25",
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        {
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        },
        {
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        }
      ],
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        {
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          "minimum": 44.1006,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASO 12FR",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A435",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 134.3529,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #4 051114-10",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 82.7313,
          "maximum": 189.6301,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC",
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        {
          "code": "3559672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 116.5759,
          "maximum": 1016.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 3.5X65",
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        {
          "code": "3559673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 624.929,
          "maximum": 1326.5796,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 928.6057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURETTE-0* TIP TDC005",
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        {
          "code": "3559688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 745.6073,
          "maximum": 1582.7517,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1107.9262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-0* TIP NAVIGATION",
      "code_information": [
        {
          "code": "3559690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 676.8924,
          "maximum": 5458.1215,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON SILK    C-021-",
      "code_information": [
        {
          "code": "3560079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PS-2/4-0   J496G",
      "code_information": [
        {
          "code": "3560474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J492G",
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        {
          "code": "3560778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J493G",
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        {
          "code": "3560802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J494G",
      "code_information": [
        {
          "code": "3560836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 4-0  J-496-H",
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        {
          "code": "3560879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 20.17,
          "maximum": 42.8163,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-497-G",
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        {
          "code": "3560893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 21.8794,
          "maximum": 95.6492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-774-D",
      "code_information": [
        {
          "code": "3561255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 7.7854,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 87.3743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J762D",
      "code_information": [
        {
          "code": "3561415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 7.7854,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 98.5501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0        699H",
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        {
          "code": "3561696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 7.7854,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y496G",
      "code_information": [
        {
          "code": "3562112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 7.7854,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.7351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y494G",
      "code_information": [
        {
          "code": "3562131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS-2    1666",
      "code_information": [
        {
          "code": "3562141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 40,
          "minimum": 13.6746,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 20.3196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8619G",
      "code_information": [
        {
          "code": "3562217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 7.7854,
          "maximum": 82.0041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8699G",
      "code_information": [
        {
          "code": "3562235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 7.7854,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIVERSAL*****",
      "code_information": [
        {
          "code": "3566070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 92.8896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-EAR DAVOL 3 OZ 529****",
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        {
          "code": "3566353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 112.3322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.4155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CT FAST LOAD DUAL",
      "code_information": [
        {
          "code": "3566355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 66.732,
          "maximum": 146.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-PACK DUAL EMPOWERCTA",
      "code_information": [
        {
          "code": "3566380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 3586.845,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 113.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CRANIAL ACCESS  INSHITH",
      "code_information": [
        {
          "code": "3566755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2554,
          "minimum": 546.0902,
          "maximum": 1853.4378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1297.4065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MULTI PODUS 9274-56XX",
      "code_information": [
        {
          "code": "3566785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 982,
          "minimum": 74.5174,
          "maximum": 712.6374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 498.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NURSING SUPPLEMENTAL",
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        {
          "code": "3566790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.0707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FECAL MANAGEMENT",
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        {
          "code": "3566823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1240,
          "minimum": 40.5953,
          "maximum": 899.868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 629.9076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-REPLACEMENT FECAL MGMT",
      "code_information": [
        {
          "code": "3566824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 512.1681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3567605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 921,
          "minimum": 104.5468,
          "maximum": 668.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 467.8588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "THERMOSET-INJECTATE    4142403",
      "code_information": [
        {
          "code": "3568123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 3118.0527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 8.0MM",
      "code_information": [
        {
          "code": "3568561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 445,
          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 226.0555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 6.0MM",
      "code_information": [
        {
          "code": "3568562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 450,
          "minimum": 153.8392,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3568563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 152.1299,
          "maximum": 322.9365,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 508,
          "minimum": 173.6673,
          "maximum": 368.6556,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 258.0589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU UNCUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 99.5419,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 218.4357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4259105",
      "code_information": [
        {
          "code": "3568757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 380,
          "minimum": 84.5272,
          "maximum": 275.766,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 193.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-NEONATAL   42634-05",
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        {
          "code": "3568760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 51.9635,
          "maximum": 121.7859,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 77.2145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXISENSOR-PEDIATRIC D20",
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        {
          "code": "3568762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 630.0613,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 111.2498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565200",
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        {
          "code": "3569240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 387.3329,
          "maximum": 822.2181,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 575.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565150",
      "code_information": [
        {
          "code": "3569242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 203.5326,
          "maximum": 822.2181,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 575.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16 FR",
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        {
          "code": "3569250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 125.1225,
          "maximum": 265.6062,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 185.9243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18 FR",
      "code_information": [
        {
          "code": "3569252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 11.122,
          "maximum": 265.6062,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 185.9243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH URETHRAL BARD 772415",
      "code_information": [
        {
          "code": "3569258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 6.8373,
          "maximum": 608.9295,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 10.1598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-ESOPH TRACH     5-18541",
      "code_information": [
        {
          "code": "3569601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1095,
          "minimum": 40.5953,
          "maximum": 794.6415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 556.249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY CATH/DRN BAG 6176LL",
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        {
          "code": "3569779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR   6146LL",
      "code_information": [
        {
          "code": "3569805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 68.9415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/ BAG 18FR  6148LL",
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        {
          "code": "3569853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 36.5795,
          "maximum": 77.6499,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 54.3549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG LTX 16F 6165L",
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        {
          "code": "3569870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 32.819,
          "maximum": 15394.5163,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 48.767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LOOP CCL DYNJ50892",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 103.9269,
          "maximum": 220.6128,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 154.429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMBAR PUNCTURE ADT 4301C",
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        {
          "code": "3570322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 69.5125,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 184.4004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMB PUNC PED   4304C****",
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        {
          "code": "3570330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 310.3038,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 63.4987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR PROC OP DYNJ31942F",
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        {
          "code": "3570410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 65.0637,
          "maximum": 404.9406,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 283.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PARA/PUD PHARMASEAL 4540A",
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        {
          "code": "3570603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 39.9982,
          "maximum": 540.5292,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 6.0F",
      "code_information": [
        {
          "code": "3570605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 705.3804,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 493.7663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 8.3F",
      "code_information": [
        {
          "code": "3570610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 382.0407,
          "maximum": 878.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SINGLE TAP BLOCK SPEC015",
      "code_information": [
        {
          "code": "3570640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 234.8612,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 348.9891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-NICU UMBILICAL CATH",
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        {
          "code": "3570745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 185.6326,
          "maximum": 394.0551,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 275.8386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-THORACENTESIS CURITY 5014*",
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        {
          "code": "3571304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 404.8408,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 143.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 16FR 0100-16LV",
      "code_information": [
        {
          "code": "3571985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 87.8638,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 192.0202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING W/ST 10F 43\\\"",
      "code_information": [
        {
          "code": "3571990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 177.952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.2624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 8.0     86552",
      "code_information": [
        {
          "code": "3572176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 413.1823,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.5568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 6LPC",
      "code_information": [
        {
          "code": "3572189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 743,
          "minimum": 201.8643,
          "maximum": 539.1951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 377.4366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 6CFS",
      "code_information": [
        {
          "code": "3572191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 281.9427,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.4004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 6MM",
      "code_information": [
        {
          "code": "3572195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 507,
          "minimum": 173.3255,
          "maximum": 559.9927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.5509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRP MIC-KEY 14FR 1.5CM",
      "code_information": [
        {
          "code": "3572305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 344.2579,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 511.5459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 35FR     125135",
      "code_information": [
        {
          "code": "3572307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 352.5451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 39FR     125139",
      "code_information": [
        {
          "code": "3572309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 352.5451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 41FR     125141",
      "code_information": [
        {
          "code": "3572311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 237.2542,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 352.5451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 37FR LFT 125037",
      "code_information": [
        {
          "code": "3572315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 619,
          "minimum": 211.6143,
          "maximum": 1485.8992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 314.4458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BLAKEMORE 20 FR      9210",
      "code_information": [
        {
          "code": "3572344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2672,
          "minimum": 40.5953,
          "maximum": 1939.0704,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1357.3493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 5F 20\\\"     461412",
      "code_information": [
        {
          "code": "3572425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 6.5F 36\\\"   461438",
      "code_information": [
        {
          "code": "3572430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 77.2979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASOGASTRIC 8FR",
      "code_information": [
        {
          "code": "3572485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 131.7957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.6106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 18FR 20CC",
      "code_information": [
        {
          "code": "3572530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 237,
          "minimum": 48.3807,
          "maximum": 171.9909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 120.3936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.5       86215",
      "code_information": [
        {
          "code": "3572860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.1951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.0       8621",
      "code_information": [
        {
          "code": "3572863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.1951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.0       86212",
      "code_information": [
        {
          "code": "3572865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.1951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.5       86213",
      "code_information": [
        {
          "code": "3572866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.1951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 8.0C      86216",
      "code_information": [
        {
          "code": "3572867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 63.1359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.1951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "3573037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.4954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "3573039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 393.1627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.4954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM",
      "code_information": [
        {
          "code": "3573355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 359.1489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 8MM",
      "code_information": [
        {
          "code": "3573357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 707,
          "minimum": 241.6985,
          "maximum": 513.0699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 359.1489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF    SZs  DCTs",
      "code_information": [
        {
          "code": "3573530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 461,
          "minimum": 157.5997,
          "maximum": 334.5477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 234.1834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FENESTRATED SZ 4TO10  CFN",
      "code_information": [
        {
          "code": "3573565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 1622.6998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 174.2406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH #6   518035",
      "code_information": [
        {
          "code": "3573650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 413.1823,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 8FR     8LPC",
      "code_information": [
        {
          "code": "3573714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 743,
          "minimum": 177.952,
          "maximum": 539.1951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 377.4366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,TRAC REINFO 6.0 86548",
      "code_information": [
        {
          "code": "3573730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.5568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 7.0     86550",
      "code_information": [
        {
          "code": "3573735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 237.4547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.5568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEEY PED",
      "code_information": [
        {
          "code": "3573845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 427,
          "minimum": 145.9763,
          "maximum": 324.2063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 216.9117,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 583,
          "minimum": 199.3072,
          "maximum": 423.0831,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 296.1582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 520,
          "minimum": 177.7697,
          "maximum": 377.364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 264.1548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 0.8MM",
      "code_information": [
        {
          "code": "3573906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 501,
          "minimum": 171.2743,
          "maximum": 363.5757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 254.503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3573910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 435,
          "minimum": 148.7112,
          "maximum": 315.6795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.9756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF BLU 10.0MM",
      "code_information": [
        {
          "code": "3573911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 6.0MM",
      "code_information": [
        {
          "code": "3573914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 778.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 6.0MM",
      "code_information": [
        {
          "code": "3573915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1400,
          "minimum": 478.6108,
          "maximum": 1015.98,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 711.186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 8.0MM",
      "code_information": [
        {
          "code": "3573916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 229.6693,
          "maximum": 816.4125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 571.4887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF 7.0MM",
      "code_information": [
        {
          "code": "3573920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 413,
          "minimum": 141.1902,
          "maximum": 373.6992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 209.7999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 60A160",
      "code_information": [
        {
          "code": "3573926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 672,
          "minimum": 229.7332,
          "maximum": 487.6704,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 341.3693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 7MM",
      "code_information": [
        {
          "code": "3573937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.4357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE XL 7",
      "code_information": [
        {
          "code": "3573950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 40.5953,
          "maximum": 816.4125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 571.4887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNDERPAD-CGLIDE XL 40X80 PK",
      "code_information": [
        {
          "code": "3574527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 69.5125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-D&C COLLECTION 23116",
      "code_information": [
        {
          "code": "3574563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 367.5821,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.4987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-MITY-ONE MYSTIC   10058",
      "code_information": [
        {
          "code": "3574642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 661,
          "minimum": 33.9221,
          "maximum": 479.6877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 335.7814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI-REFLUX",
      "code_information": [
        {
          "code": "3574651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 488.8119,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING TRACH    PMV007",
      "code_information": [
        {
          "code": "3574654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 879,
          "minimum": 300.4992,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 446.5232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAX-BONE                  W31G",
      "code_information": [
        {
          "code": "3575105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 152.3714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.6712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER PK",
      "code_information": [
        {
          "code": "3575110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 230.2254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 139.1893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER XLPK",
      "code_information": [
        {
          "code": "3575115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 414,
          "minimum": 77.2979,
          "maximum": 300.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 210.3079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-FOAM POSITIONING DISP",
      "code_information": [
        {
          "code": "3575122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 180.1764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.6106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MEDTRONIC ATRIAL    6492F",
      "code_information": [
        {
          "code": "3575572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 99.5419,
          "maximum": 235.1268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK L/XL",
      "code_information": [
        {
          "code": "3575890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 235.8525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.0967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-THROMBIDISC TOPICAL HEMO",
      "code_information": [
        {
          "code": "3575891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 230.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.0614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD S/M",
      "code_information": [
        {
          "code": "3575892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 301.1655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 210.8158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD L/XL",
      "code_information": [
        {
          "code": "3575893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 518,
          "minimum": 177.086,
          "maximum": 375.9126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 263.1388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-LEG POSITIONER 111618",
      "code_information": [
        {
          "code": "3575894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 174.2406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK S/M",
      "code_information": [
        {
          "code": "3575895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 30.5855,
          "maximum": 196.6647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.6653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRISTLET-PORTHOLE 6600021150",
      "code_information": [
        {
          "code": "3576870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.9394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH 442-2",
      "code_information": [
        {
          "code": "3576880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 41.1514,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EXUDE HYDRO 6X6",
      "code_information": [
        {
          "code": "3580000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 76.1857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.5913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-OPTICELL AG+4X5",
      "code_information": [
        {
          "code": "3580001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 137,
          "minimum": 46.8355,
          "maximum": 104.5468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.5946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 16FR",
      "code_information": [
        {
          "code": "3580005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST RT XS 8",
      "code_information": [
        {
          "code": "3580008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.7065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LT XS 8",
      "code_information": [
        {
          "code": "3580009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 102.8785,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 EASY CAP II",
      "code_information": [
        {
          "code": "3580015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 171,
          "minimum": 58.4589,
          "maximum": 124.0947,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.8663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 14FR",
      "code_information": [
        {
          "code": "3580016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 145.6982,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-NASAL L/R STANDARD",
      "code_information": [
        {
          "code": "3580017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 262,
          "minimum": 47.2685,
          "maximum": 190.1334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 133.0934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT MED CLOSED",
      "code_information": [
        {
          "code": "3580023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 100.098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,OVAL 5.5X13CM AR-8550COE",
      "code_information": [
        {
          "code": "3580025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 815.7987,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 230.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3590000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1467,
          "minimum": 210.2058,
          "maximum": 1064.6019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 745.2213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTROSTOMY 18FR   100-18",
      "code_information": [
        {
          "code": "3590008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 192.0202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY BASIC         4380",
      "code_information": [
        {
          "code": "3590013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 301,
          "minimum": 102.9013,
          "maximum": 218.4357,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSAL 10FR  15642-001",
      "code_information": [
        {
          "code": "3590100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 385.3773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REPAIR ASH CATH      RPK01",
      "code_information": [
        {
          "code": "3590134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 693,
          "minimum": 207.4253,
          "maximum": 502.9101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 352.0371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 99.5419,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.3844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LMH LMH-1001",
      "code_information": [
        {
          "code": "3598009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 207.4253,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1363.9531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 03.130.302",
      "code_information": [
        {
          "code": "3598013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 2920.6372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 525.7696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-BLUE RHINO G2",
      "code_information": [
        {
          "code": "3598017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1449.2955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-STERLING 3.0X60X150",
      "code_information": [
        {
          "code": "3598023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1841,
          "minimum": 41.7075,
          "maximum": 1336.0137,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 935.2096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORGANIZER-7 DAY PILL 70069L",
      "code_information": [
        {
          "code": "3598024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 78.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.0992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I-KNIFE II 8065921502",
      "code_information": [
        {
          "code": "3598025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 142,
          "minimum": 48.5448,
          "maximum": 103.0494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.1346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPEN KNEE ABS-2001-OT",
      "code_information": [
        {
          "code": "3598069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 4266.3992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2435.812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE GEL",
      "code_information": [
        {
          "code": "3598076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 41.1514,
          "maximum": 181.425,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 126.9975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACEMENT GEL",
      "code_information": [
        {
          "code": "3598077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 139.025,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.5913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER GEL",
      "code_information": [
        {
          "code": "3598078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 85.4662,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-SAMPLE EXTENSION 1841-25",
      "code_information": [
        {
          "code": "3598081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 6399.5988,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 88.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-8MM ENT TUBE NVM5 2010480",
      "code_information": [
        {
          "code": "3598086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2289,
          "minimum": 782.5287,
          "maximum": 15669.2297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1162.7891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-9WX7L AR-8717-0907",
      "code_information": [
        {
          "code": "3598104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 32790.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-MEGADYNE 10FT SMOKE",
      "code_information": [
        {
          "code": "3598109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 55.61,
          "maximum": 169.0881,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 118.3617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MEGADYNE F/SMOKE",
      "code_information": [
        {
          "code": "3598110",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 196.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 50.799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ZIP PEN F/SMOKE EVAC",
      "code_information": [
        {
          "code": "3598111",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 121.0202,
          "maximum": 310.8599,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 179.8285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER SO SPECTRUM SU",
      "code_information": [
        {
          "code": "3598112",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 191.1025,
          "maximum": 405.6663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 283.9664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER S1 SPECTRUM SU",
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        {
          "code": "3598113",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 33.9221,
          "maximum": 405.6663,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 283.9664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1603G",
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        {
          "code": "3598114",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 1661G",
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        {
          "code": "3598115",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 25.298,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 37.5913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MINIVAC MGVSFT10",
      "code_information": [
        {
          "code": "3598117",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 454.8898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.1026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHTMAT-ULTRATHIN UA2550",
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        {
          "code": "3598118",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 818,
          "minimum": 279.6455,
          "maximum": 593.6226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 415.5358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MEGADYN SPECULUM 23951",
      "code_information": [
        {
          "code": "3598134",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 202,
          "minimum": 69.0567,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-221C-0427",
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        {
          "code": "3598154",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 5197.8667,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 404.36,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLIDE-OCULAR KDB GLIDE",
      "code_information": [
        {
          "code": "3598156",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 207.4253,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1687.5428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROVU DISP PHB-03",
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        {
          "code": "3598158",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1230.6493,
          "maximum": 8069.0583,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5648.3408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BLUGRIGGS PERC DILATION",
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        {
          "code": "3598159",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 756.5469,
          "maximum": 5157.8275,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1124.1819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5X10 AR-8610TDC-01C",
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        {
          "code": "3598172",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 12007.8673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1193.2685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-EGG 4.0MM 5820-015-040",
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        {
          "code": "3598178",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 2.0 6007-1200",
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        {
          "code": "3598184",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 4999.339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 493.2583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY SZ 8 8DCFS",
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        {
          "code": "3598187",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 194.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBT 7MM EMG ET 2010470",
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        {
          "code": "3598201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 782.5287,
          "maximum": 1661.1273,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1162.7891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LAPIPLASTY 40X11 SM-4011",
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        {
          "code": "3598213",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 204.0933,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 3.2 HAMMER 702632",
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        {
          "code": "3598233",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4242,
          "minimum": 870.8526,
          "maximum": 3078.4194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2154.8936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK DS AR-8991DS",
      "code_information": [
        {
          "code": "3598238",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1938,
          "minimum": 662.5341,
          "maximum": 4743.533,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 984.4846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 PLUS VCP317H",
      "code_information": [
        {
          "code": "3598242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 3.4186,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5.0799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM CSS-072-37-SQ",
      "code_information": [
        {
          "code": "3598257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1052.9907,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 737.0935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-25 G00896",
      "code_information": [
        {
          "code": "3598279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 193,
          "minimum": 65.9799,
          "maximum": 1556.5239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 98.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HIGH TORQUE 70-2001",
      "code_information": [
        {
          "code": "3598282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1378,
          "minimum": 36.7026,
          "maximum": 1000.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 700.0102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP523H",
      "code_information": [
        {
          "code": "3598283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.5273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.3MM AR-7535",
      "code_information": [
        {
          "code": "3598289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 1101.078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 379.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYNGECTOMY SZ10 6132",
      "code_information": [
        {
          "code": "3598291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2343,
          "minimum": 46.7124,
          "maximum": 1700.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1190.2206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-PREFILL AREOSOL 500M",
      "code_information": [
        {
          "code": "3598292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.6712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUNCTURE 17FR/10MM 8141US",
      "code_information": [
        {
          "code": "3598296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2695,
          "minimum": 921.3258,
          "maximum": 8230.28,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1369.033,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORCAPOD SUCTION BIOPSY",
      "code_information": [
        {
          "code": "3598300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 46.1563,
          "maximum": 116.8377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.7864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-E-Z CLEAN 0016AM",
      "code_information": [
        {
          "code": "3598301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 6499.6968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.1632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL 80M 04.038.380S",
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        {
          "code": "3598333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4478,
          "minimum": 1530.8708,
          "maximum": 3249.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2274.7792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153204",
      "code_information": [
        {
          "code": "3598338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 8315.3633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 SURGILON 8886195151",
      "code_information": [
        {
          "code": "3598362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 42.8163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 SURGILON 8886195141",
      "code_information": [
        {
          "code": "3598363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.5913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEO TEE 1050810",
      "code_information": [
        {
          "code": "3598397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 209.0016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 146.3011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 10.5 CLR",
      "code_information": [
        {
          "code": "3598403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 201.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.5114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY L-WIRE 20115",
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        {
          "code": "3598404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 362,
          "minimum": 123.7551,
          "maximum": 345.3381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.8924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-LIGATING SURGITIE SGL-1",
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        {
          "code": "3598405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 621,
          "minimum": 7.7854,
          "maximum": 450.6597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 315.4618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 11 96\\\" Z880G",
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        {
          "code": "3598407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 1146.6782,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-POWER 45MM FLEX PSEE45",
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        {
          "code": "3598408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2062,
          "minimum": 31.6977,
          "maximum": 1496.3934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1047.4754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 32FR 056132",
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        {
          "code": "3598409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 19.4863,
          "maximum": 126.7908,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 28.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SOFSIK 2-0 18\\\" GS63M",
      "code_information": [
        {
          "code": "3598410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 7.7854,
          "maximum": 165.4596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.8217,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOSOF 5-0 SN-661",
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        {
          "code": "3598412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 36.2377,
          "maximum": 81.7467,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1 G48",
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        {
          "code": "3598413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 7.7854,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.6745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0 3844G",
      "code_information": [
        {
          "code": "3598415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.1026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 714G",
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        {
          "code": "3598417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.1472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD WARMING RAPID 24355",
      "code_information": [
        {
          "code": "3598418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 134.5762,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 224.5316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTOLOGY 2.3MMX240CM",
      "code_information": [
        {
          "code": "3598419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 78.4101,
          "maximum": 175.6194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.9336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY LONG 2.4MM E1450-6",
      "code_information": [
        {
          "code": "3598420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 7.7854,
          "maximum": 102.3237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.6266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y527H",
      "code_information": [
        {
          "code": "3598424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 239.123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-GRAVITY SPIKE FLUID MGMT",
      "code_information": [
        {
          "code": "3598425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 127.3469,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 218.4357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEM SILVER 6.5X7",
      "code_information": [
        {
          "code": "3598426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 166.1853,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 116.3297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 20FR 5CC",
      "code_information": [
        {
          "code": "3598427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 183.513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.6266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-J-TIP .035X145CM",
      "code_information": [
        {
          "code": "3598428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 330,
          "minimum": 81.1906,
          "maximum": 239.481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.6367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 30CC 16FR",
      "code_information": [
        {
          "code": "3598429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 146,
          "minimum": 49.9123,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.1665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2 490T",
      "code_information": [
        {
          "code": "3598434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII BLADED CTB33",
      "code_information": [
        {
          "code": "3598436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.0648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM BLADELESS CTR03",
      "code_information": [
        {
          "code": "3598437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND 10FR DYNJWE1321A",
      "code_information": [
        {
          "code": "3598439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 109,
          "minimum": 37.2633,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ULNAR NERVE 79-91100",
      "code_information": [
        {
          "code": "3598441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 947.0383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.0193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POWDER-HEMOSTAT AVITENE 1 GRAM",
      "code_information": [
        {
          "code": "3598442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1703,
          "minimum": 362.5772,
          "maximum": 1235.8671,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 865.107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RADIAL ARTERY 20GX1.75\\\"",
      "code_information": [
        {
          "code": "3598444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 265,
          "minimum": 90.5942,
          "maximum": 464.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 134.6173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL RHINO ROCKET LRG",
      "code_information": [
        {
          "code": "3598446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 368.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.6653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-FOREIGN BODY 60613",
      "code_information": [
        {
          "code": "3598447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 663,
          "minimum": 31.6977,
          "maximum": 481.1391,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 24FR 056124",
      "code_information": [
        {
          "code": "3598448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 121.2298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-HYDROFERA 6X6 HB6614",
      "code_information": [
        {
          "code": "3598449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 158.2026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SMALL WIDE",
      "code_information": [
        {
          "code": "3598450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 254.1377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.2498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARYNGECTOMY SZ6 6LGT",
      "code_information": [
        {
          "code": "3598451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 457,
          "minimum": 156.2322,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 232.1514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X285MM 703586",
      "code_information": [
        {
          "code": "3598458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 566,
          "minimum": 193.4955,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 566,
          "minimum": 193.4955,
          "maximum": 471.5728,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 18FR",
      "code_information": [
        {
          "code": "3598463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 711.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 497.8302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1125,
          "minimum": 384.598,
          "maximum": 4441.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 571.4887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATFORM-GELPOINT PATH CNB11",
      "code_information": [
        {
          "code": "3598471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1687.4449,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2507.4386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VINYL CONNECTING G02791",
      "code_information": [
        {
          "code": "3598473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 78.9708,
          "maximum": 179.6203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 117.3457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRUIT, CROSS VENT 80011",
      "code_information": [
        {
          "code": "3598474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 323,
          "minimum": 110.4223,
          "maximum": 234.4011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR, NEO W/MASK",
      "code_information": [
        {
          "code": "3598475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 342,
          "minimum": 116.9178,
          "maximum": 533.2999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 173.7326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3598478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 71.1808,
          "maximum": 565.3203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 395.7242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC #1 48G",
      "code_information": [
        {
          "code": "3598479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3287.6632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STEM 222-496100",
      "code_information": [
        {
          "code": "3598480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5912,
          "minimum": 2021.1051,
          "maximum": 4290.3384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3003.2369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRIP-PLATINUM MS04R-IP10X-0JH",
      "code_information": [
        {
          "code": "3598481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4118,
          "minimum": 1407.7995,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2091.9028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-ENDOCAPSULE 10 MAJ2027",
      "code_information": [
        {
          "code": "3598483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3003,
          "minimum": 402.6164,
          "maximum": 2179.2771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1525.494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-10G/7.75\\\" 0306-810-000",
      "code_information": [
        {
          "code": "3598484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 724,
          "minimum": 247.5102,
          "maximum": 525.4068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 367.7848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77420",
      "code_information": [
        {
          "code": "3598485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 584,
          "minimum": 199.6491,
          "maximum": 30448.6994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 296.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/SUPPORT #6",
      "code_information": [
        {
          "code": "3598487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 784,
          "minimum": 268.0221,
          "maximum": 568.9488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 398.2642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST 4050-100N",
      "code_information": [
        {
          "code": "3598488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 1676.0854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 358.6409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-GONIOTOMY TRABEX 600042",
      "code_information": [
        {
          "code": "3598489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3014,
          "minimum": 784.101,
          "maximum": 2187.2598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1531.0819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-STRAIGHT JAW NSLX137S",
      "code_information": [
        {
          "code": "3598493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2542,
          "minimum": 869.0205,
          "maximum": 1844.7294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1291.3106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW NSLX137C",
      "code_information": [
        {
          "code": "3598494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2637,
          "minimum": 901.4976,
          "maximum": 1913.6709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1339.5696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JADA POSTPARTUM",
      "code_information": [
        {
          "code": "3598497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5844,
          "minimum": 1997.8582,
          "maximum": 5012.6854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2968.6936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA G PROCEDURAL PUG",
      "code_information": [
        {
          "code": "3598498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9014,
          "minimum": 580.0123,
          "maximum": 6541.4598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4579.0219,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-4MM/SHORT 1149.8052",
      "code_information": [
        {
          "code": "3598502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 872.0973,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1295.8825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN",
      "code_information": [
        {
          "code": "3598508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 583.6805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94975",
      "code_information": [
        {
          "code": "3598515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1030,
          "minimum": 352.1208,
          "maximum": 747.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 523.2297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYN W/EL SZ10 6136",
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        {
          "code": "3598520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4004,
          "minimum": 245.7962,
          "maximum": 2905.7028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2033.992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.4X100/LG AGK10100",
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        {
          "code": "3598521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 1475.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 224.5316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X120MM 45302001",
      "code_information": [
        {
          "code": "3598524",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 200.1481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNIT-TI-KNOT QUICK LOAD 030510",
      "code_information": [
        {
          "code": "3598527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PICO 14 WOUND 15X30CM",
      "code_information": [
        {
          "code": "3598530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1724,
          "minimum": 589.375,
          "maximum": 1251.1068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 875.7748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
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        {
          "code": "3598531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1590,
          "minimum": 543.5651,
          "maximum": 2600.3236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 807.7041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY STANDARD 7607",
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        {
          "code": "3598534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1347,
          "minimum": 42.8197,
          "maximum": 977.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 684.2625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND XTRASORB 6X9",
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        {
          "code": "3598535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 1016.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
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        {
          "code": "3598536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1828,
          "minimum": 32.2538,
          "maximum": 1326.5796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 928.6057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS SELECT",
      "code_information": [
        {
          "code": "3598538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 831.9256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY",
      "code_information": [
        {
          "code": "3598539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1496,
          "minimum": 511.4298,
          "maximum": 1085.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 759.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LK/MD 3.1X328 705077",
      "code_information": [
        {
          "code": "3598547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1526,
          "minimum": 207.4253,
          "maximum": 1107.4182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 775.1927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E-CATH PLUS 251285-41E",
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        {
          "code": "3598551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 14240.6088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-OVAL CUP BIOPSY SINGLE",
      "code_information": [
        {
          "code": "3598561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 424.5345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 297.1741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEATED W/GAS FILTER",
      "code_information": [
        {
          "code": "3598562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 652,
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          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-10X360/RT/130* 3430-0360S",
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        {
          "code": "3598565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 933.1358,
          "maximum": 4555.2189,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X65MM 03.130.201",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 380.8375,
          "maximum": 808.4298,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-AIRSEAL CANN 8MM IAS8-DV",
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        {
          "code": "3598593",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "maximum": 814.9611,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTERD FURCATED ASM-EVAC",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "maximum": 1056.59,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS + MAP152",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 69.0567,
          "maximum": 1228.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRIVE T6 VARIAX2 705132",
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        {
          "code": "3598602",
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        },
        {
          "code": "0270",
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        }
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        {
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          "minimum": 755.5213,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREW T7 AO 45-27015",
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        {
          "code": "3598609",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 526.4719,
          "maximum": 3684.1625,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROXIMATE PROCEDURE PPH03",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 556.6561,
          "maximum": 1936.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X7MM 60-16007",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 461.1757,
          "maximum": 1138.3367,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.9X115/35MM 92-19135",
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        {
          "code": "3598625",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 699.7974,
          "maximum": 1485.5079,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 47.8611,
          "maximum": 9787.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
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        {
          "code": "3598631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 89.9105,
          "maximum": 4627.8642,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-EDIPURAL 17GX3.5 BUPIV",
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        {
          "code": "3598647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 99.5419,
          "maximum": 262.7034,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 0.3MM DWD055",
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        {
          "code": "3598653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 207.4253,
          "maximum": 1007.9973,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #2",
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        {
          "code": "3598662",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
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    {
      "description": "KIT-PEDICLE ACCESS 624.027S",
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        {
          "code": "0270",
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      ],
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        {
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          "minimum": 1542.8361,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
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        {
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 270.2646,
          "maximum": 706.8318,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 24FR 77424",
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        {
          "code": "3598679",
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 166.1463,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X13MM AR-300-B001",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 1700.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X19.5MM AR-300-B201",
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        },
        {
          "code": "0270",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8710H",
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        {
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        },
        {
          "code": "0270",
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        {
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          "payers_information": [
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8725H",
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        },
        {
          "code": "0270",
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      ],
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            {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8806H",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 109.3968,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8718H",
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        {
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        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 88.2011,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8714H",
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          "code": "3598699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 73.5009,
          "maximum": 460.4508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W SPPRT MXPRSK05",
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        {
          "code": "3598700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 283.0641,
          "maximum": 31654.8803,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-BENSTON 260CM/.035\\\"",
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        {
          "code": "3598702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 72.4754,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/ SUPPORT #3",
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        {
          "code": "3598704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 828,
          "minimum": 283.0641,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 420.6157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-LT 130°/10X420 3530-0420S",
      "code_information": [
        {
          "code": "3598705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6277,
          "minimum": 2145.8857,
          "maximum": 4555.2189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3188.6532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-XI 45MM 480445",
      "code_information": [
        {
          "code": "3598714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3242,
          "minimum": 7.7854,
          "maximum": 2352.7194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1646.9036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-MUSTANG 7.0X20X135CM",
      "code_information": [
        {
          "code": "3598729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 691.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT,ACTIVE ANKLE HEEL-LOCK",
      "code_information": [
        {
          "code": "3598758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 464,
          "minimum": 150.7031,
          "maximum": 336.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 235.7074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR,SURGICEL 3123SPEA",
      "code_information": [
        {
          "code": "3598761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 322,
          "minimum": 110.0805,
          "maximum": 2901.7298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP ESREC",
      "code_information": [
        {
          "code": "3598782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.6552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 3.0X2.1 45-30005",
      "code_information": [
        {
          "code": "3598799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1849,
          "minimum": 632.1081,
          "maximum": 1341.8193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 939.2735,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-8737-37",
      "code_information": [
        {
          "code": "3598812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE,.045\\\" THD AR-8737-05",
      "code_information": [
        {
          "code": "3598815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 7942.7763,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO 2.0MM DC6106",
      "code_information": [
        {
          "code": "3598843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 199.0838,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 886.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.5X150MM 58862515",
      "code_information": [
        {
          "code": "3598844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM DSDS1011",
      "code_information": [
        {
          "code": "3598845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.5MM DSDS0025",
      "code_information": [
        {
          "code": "3598846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 968.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.0MM DSDS0030",
      "code_information": [
        {
          "code": "3598853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 968.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR SHEEHY 510-131C",
      "code_information": [
        {
          "code": "3598870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 148.7685,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F X-FIT 60-80323",
      "code_information": [
        {
          "code": "3598874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1052.9907,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 737.0935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F 1.7MM 60-80317",
      "code_information": [
        {
          "code": "3598875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1451,
          "minimum": 496.0459,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 737.0935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EAR-SPEEDIWICK 15MM OT-5201-50",
      "code_information": [
        {
          "code": "3598882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.1312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 15CM APYX-15-TP",
      "code_information": [
        {
          "code": "3598955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3007,
          "minimum": 1027.9876,
          "maximum": 2182.1799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1527.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERIOTOMY",
      "code_information": [
        {
          "code": "3598957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 207.4253,
          "maximum": 640.7931,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 448.5552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/46-62\\\" 1143PP",
      "code_information": [
        {
          "code": "3598975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 6.0 BIPOLAR",
      "code_information": [
        {
          "code": "3598997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2604,
          "minimum": 890.2161,
          "maximum": 3668.0356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1322.806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 004025",
      "code_information": [
        {
          "code": "3599029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 91.4382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-WIGGLE OPTIFLOW JR 2 M",
      "code_information": [
        {
          "code": "3599030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 10911.2381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.65MM MD 45303065",
      "code_information": [
        {
          "code": "3599049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 583.6805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.55MM MD 45303055",
      "code_information": [
        {
          "code": "3599050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 583.6805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8305H",
      "code_information": [
        {
          "code": "3599073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 1132.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.3137,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-S-CURVE URETH DIL G32789",
      "code_information": [
        {
          "code": "3599074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2036,
          "minimum": 696.0369,
          "maximum": 1477.5252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1034.2676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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          ]
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      "service_type": "CDM"
    },
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      "description": "GUIDE-MAGNETIC PATH GPM100",
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        {
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        },
        {
          "code": "0270",
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      ],
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        {
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          "maximum": 4073.3541,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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          ]
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      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002352",
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          "type": "LOCAL"
        },
        {
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        }
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        {
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002351",
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        {
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        },
        {
          "code": "0270",
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        }
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        {
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          "minimum": 773.2983,
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            {
              "payer_name": "Anthem",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
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        }
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        {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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        },
        {
          "code": "0270",
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      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
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        },
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        }
      ],
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        {
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            {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-270-330C ALLOX-FH12SE",
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        },
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          "code": "0270",
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        }
      ],
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        {
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          "minimum": 207.4253,
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.3MM CSS-040-23",
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        },
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          "code": "0270",
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        }
      ],
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        {
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          "maximum": 9651.6716,
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-NAIL 3MM 4150004025",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-FULL VIP1137430",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 91.9616,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FILL VIP1137431",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 97.0896,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #4",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 297.4224,
          "maximum": 631.359,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-HINGED KNEE LG 11-0672-4",
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        {
          "code": "3599145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 207.4253,
          "maximum": 632.8104,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-PROCESSOR DEPTH Z179994",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 828.3386,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X230/200MM 315.93",
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        {
          "code": "3599157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 624.2452,
          "maximum": 11446.7624,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TENSIONER-CERCLAGE AR-7820",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CERCLAGE STR/LG AR-7822",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-INS MID/HINDFOOT FFSP1530",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 860.4739,
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            {
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LP PRP LEUKOCYTE POOR PRS6",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-4160-40",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SET RENOVARP GIS-30",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/135X45 03.133.102",
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        },
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SYSTEM-100.783+/3H 954-0035",
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        },
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PARACENTESIS GIS-31",
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        },
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        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MALE EXT PWM-030 PUREWICK",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 2 1/2\\\"",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 24.6143,
          "maximum": 52.2504,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 3\\\"",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-PLANTAR KERATOSIS WOMENS",
      "code_information": [
        {
          "code": "3599300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" SMALL",
      "code_information": [
        {
          "code": "3599306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" MEDIUM",
      "code_information": [
        {
          "code": "3599307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.1472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" LARGE",
      "code_information": [
        {
          "code": "3599308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 53.7018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.5913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE DOUBLE",
      "code_information": [
        {
          "code": "3599309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE SINGLE",
      "code_information": [
        {
          "code": "3599310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE LEFT",
      "code_information": [
        {
          "code": "3599311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 69.6672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE RIGHT",
      "code_information": [
        {
          "code": "3599312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 139.5811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 25GX5”",
      "code_information": [
        {
          "code": "3599313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 251,
          "minimum": 85.8081,
          "maximum": 576.6757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 127.5055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3599314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1037,
          "minimum": 354.5139,
          "maximum": 1007.6532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 526.7856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXYGENATOR-PERFUSION 050715",
      "code_information": [
        {
          "code": "3599315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1812,
          "minimum": 619.4591,
          "maximum": 1314.9684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 920.4779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-Y TYPE PERFUSION 10004",
      "code_information": [
        {
          "code": "3599362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 24440.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 19G X 1.5\\\"CT",
      "code_information": [
        {
          "code": "3599369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 1325.1863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.4828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM TUBING 8H23R12",
      "code_information": [
        {
          "code": "3599370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2383,
          "minimum": 814.664,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1210.5402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.7/125MM 03.133.105",
      "code_information": [
        {
          "code": "3599378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1325,
          "minimum": 452.9709,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 673.0867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-PIECE-OXYGEN MONITOR",
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        {
          "code": "3599381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 46.2271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 5ML GIS-55",
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        {
          "code": "3599412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 122.342,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.8192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-FINGER XL A8685",
      "code_information": [
        {
          "code": "3599413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 180.7325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.7578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY 040-300",
      "code_information": [
        {
          "code": "3599414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 811.906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.0967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RET 5MM/155CM FB-231D.A",
      "code_information": [
        {
          "code": "3599417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 6469.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.5089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/135X45 03.133.106",
      "code_information": [
        {
          "code": "3599424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1497,
          "minimum": 511.7717,
          "maximum": 1665.5195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 760.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL N8 PROCESSOR DUALN8",
      "code_information": [
        {
          "code": "3599512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62546,
          "minimum": 501.0461,
          "maximum": 45389.6322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31772.7425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0 EPM8703",
      "code_information": [
        {
          "code": "3599513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 901,
          "minimum": 308.0202,
          "maximum": 1582.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 457.699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.002",
      "code_information": [
        {
          "code": "3599527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 944,
          "minimum": 322.7204,
          "maximum": 48174.3869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 479.5426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOYSTICK-RED 5MM 03.211.454",
      "code_information": [
        {
          "code": "3599531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2911,
          "minimum": 497.7095,
          "maximum": 2112.5127,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1478.7589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IABC 40CC 7FR IMU7F-40",
      "code_information": [
        {
          "code": "3599539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5359,
          "minimum": 870.8526,
          "maximum": 3889.0263,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2722.3184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-SD 2MM T6 313.843.V",
      "code_information": [
        {
          "code": "3599548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1853,
          "minimum": 633.4756,
          "maximum": 1344.7221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 941.3055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIX 1.1MM DC4212",
      "code_information": [
        {
          "code": "3599593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1180,
          "minimum": 403.4005,
          "maximum": 1048.8046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 599.4282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 70MM",
      "code_information": [
        {
          "code": "3599601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 100MM",
      "code_information": [
        {
          "code": "3599602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 201,
          "minimum": 68.7148,
          "maximum": 145.8657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE SMALL",
      "code_information": [
        {
          "code": "3599607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.3743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE MEDIUM",
      "code_information": [
        {
          "code": "3599608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.3743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE LARGE",
      "code_information": [
        {
          "code": "3599609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.3743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE X-LARGE",
      "code_information": [
        {
          "code": "3599610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.3743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 3520",
      "code_information": [
        {
          "code": "3599611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.6106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4030",
      "code_information": [
        {
          "code": "3599612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.6106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4540",
      "code_information": [
        {
          "code": "3599613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 100.8723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.6106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5040",
      "code_information": [
        {
          "code": "3599614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5550",
      "code_information": [
        {
          "code": "3599615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.6106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 35-40CM",
      "code_information": [
        {
          "code": "3599617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 293,
          "minimum": 100.1664,
          "maximum": 212.6301,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 148.8411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 40-45CM",
      "code_information": [
        {
          "code": "3599618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 293,
          "minimum": 100.1664,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 148.8411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE CVD AC-20055390",
      "code_information": [
        {
          "code": "3599638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1368,
          "minimum": 467.6711,
          "maximum": 992.7576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 694.9303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE STRAIGHT",
      "code_information": [
        {
          "code": "3599639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1369,
          "minimum": 207.4253,
          "maximum": 993.4833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 695.4383,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .315\\\" NAR 200138107S",
      "code_information": [
        {
          "code": "3599664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .50\\\" WIDE 200138108S",
      "code_information": [
        {
          "code": "3599666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 19559.7053,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-BONE SCREW IB200051",
      "code_information": [
        {
          "code": "3599670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1584,
          "minimum": 541.5139,
          "maximum": 4065.6471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 804.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDES-PT SPECIFIC PROPINF",
      "code_information": [
        {
          "code": "3599671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7311,
          "minimum": 311.9721,
          "maximum": 5305.5927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3713.9149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 2.4MM 200072",
      "code_information": [
        {
          "code": "3599672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 1123.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 284.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CORNER 4.8MM 33600048",
      "code_information": [
        {
          "code": "3599673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2020,
          "minimum": 272.489,
          "maximum": 1465.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1026.1398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACID-5% ACETIC 9045052",
      "code_information": [
        {
          "code": "3599696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 55.8789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL CARE DUOCARE MDS604DC",
      "code_information": [
        {
          "code": "3599708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 270.2646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.4542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3599751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.5273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-INTERSEPT 6031",
      "code_information": [
        {
          "code": "3599752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X1/4X1/4 Y 6036",
      "code_information": [
        {
          "code": "3599753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/2X3/8X3/8 6040",
      "code_information": [
        {
          "code": "3599754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 47.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.5273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PERFUSE 1/4\\\" 10007",
      "code_information": [
        {
          "code": "3599756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 3111.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.6552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/M P01-900-1703",
      "code_information": [
        {
          "code": "3599770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 870.8526,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1374.1129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH 82-1516",
      "code_information": [
        {
          "code": "3599774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOPRO-VASOVIEW 2 VEIN",
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        {
          "code": "3599778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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      "standard_charges": [
        {
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          "minimum": 43.9319,
          "maximum": 4926.7773,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 5F 20\\\"",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 27.0073,
          "maximum": 57.3303,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 6.5F 36\\\"",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 27.0073,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UNIVERSAL PALM MEDIUM",
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        {
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        },
        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 30.0841,
          "maximum": 128.4591,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 17GX4.5\\\"",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 54.4978,
          "maximum": 167.6367,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "KIT-SPACER IN-LINE 42-RTC24-VP",
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        {
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          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 33.5028,
          "maximum": 73.9613,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRIMARY DUOVENT 1424828",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 45.468,
          "maximum": 96.5181,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-PED ANES W/FILTER",
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        {
          "code": "3599791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
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          "minimum": 48.8867,
          "maximum": 2287.2393,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
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      "service_type": "CDM"
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    {
      "description": "STAPLER-ECHELON 3000 45MM",
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        {
          "code": "0270",
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        {
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          "minimum": 982.5196,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 60MM",
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        {
          "code": "0270",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
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          "type": "LOCAL"
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 125.8063,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "BANDAGE-ROSIDAL K 10CM SHORT",
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        {
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        {
          "setting": "inpatient",
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          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 8CM SHORT",
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        {
          "code": "0270",
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        {
          "setting": "inpatient",
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          "minimum": 32.819,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    {
      "description": "COIL-LP 2MMX4CM RBYLP0204",
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        {
          "code": "0270",
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        {
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          "minimum": 870.8526,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
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        {
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "TUBE-GASTRO MIC-KEY G 18FR 2.7",
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        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING DISP FG-600U",
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        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "CANNULA-AORTIC ROOT 10012",
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        {
          "code": "0270",
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        {
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          "minimum": 77.6033,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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          ]
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    {
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          "code": "0270",
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        {
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          "minimum": 37.2587,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PROVOX XTRAFLOW HME",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "minimum": 22.9049,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "TUBE-LARY 10/36",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORA/PARA 6FRTAPS-6F-12PT",
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        {
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        },
        {
          "code": "0270",
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      ],
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        {
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          "minimum": 207.4253,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.3CM",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNOTOMY 046-367",
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        },
        {
          "code": "0270",
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      ],
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        {
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          "minimum": 215.7668,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER SM 4934-8-100",
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        {
          "code": "3600215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH14 050179",
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        {
          "code": "3600219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 183.513,
          "maximum": 704.6547,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R501-26",
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        {
          "code": "3600220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 330,
          "minimum": 112.8154,
          "maximum": 239.481,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL XS EVF1XSLA",
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        {
          "code": "3600221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 253,
          "minimum": 86.4918,
          "maximum": 183.6021,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL S-M EVF1MSLA",
      "code_information": [
        {
          "code": "3600222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 253,
          "minimum": 86.4918,
          "maximum": 183.6021,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL L EVF1LSLA",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 86.4918,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SMLSL",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 81.3638,
          "maximum": 172.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 8 5 165808",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 19.1444,
          "maximum": 1325.1863,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SZ 0 VLOCM2146",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 133.3273,
          "maximum": 325.3185,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 BARBED VLOCL0615",
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        {
          "code": "3600256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 1231.7615,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X285MM 703583",
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        {
          "code": "3600270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.4004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R502-15",
      "code_information": [
        {
          "code": "3600272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT AR-11114",
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        {
          "code": "3600273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 278,
          "minimum": 95.0384,
          "maximum": 260.2548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.2212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO 125MM AR-3210-0051",
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        {
          "code": "3600300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 231.8937,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR,SUCTION 8MM 480299",
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        {
          "code": "3600302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 638.6036,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-2.3MM INLINE DRILL MOUTH",
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        {
          "code": "3600308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2463,
          "minimum": 842.0132,
          "maximum": 6512.4871,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1251.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SPIRAL 7000AAO",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 260.2548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ONESTEP 5F OSC-5F-12PT/C",
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        {
          "code": "3600311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 468,
          "minimum": 159.9928,
          "maximum": 7277.6807,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 237.7393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NASAL ETOC2 ADT",
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        {
          "code": "3600315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 277,
          "minimum": 94.6966,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48MM EZOUT 7812-048-001K",
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        {
          "code": "3600316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2579.0652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-50MM EZOUT 7812-050-001K",
      "code_information": [
        {
          "code": "3600317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 210.2058,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2579.0652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC/SAG 5.5 2296-023-412",
      "code_information": [
        {
          "code": "3600318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 1450.8649,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 192.0202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FAT TRANS VIALITY-1400",
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        {
          "code": "3600331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1097.1853,
          "maximum": 2456.4945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1719.5461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3600343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 81.7057,
          "maximum": 2223.2878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL 3.5/2.5 AR-8943-14",
      "code_information": [
        {
          "code": "3600344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3998,
          "minimum": 232.4498,
          "maximum": 2901.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2030.944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 MONOTEX T8623",
      "code_information": [
        {
          "code": "3600351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-VISION SUCTION PROBE",
      "code_information": [
        {
          "code": "3600353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 182.9569,
          "maximum": 433.2429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-VISION PROBE ION 490127",
      "code_information": [
        {
          "code": "3600354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.1287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 19G BIOPSY",
      "code_information": [
        {
          "code": "3600355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 21G BIOPSY",
      "code_information": [
        {
          "code": "3600356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 23G BIOPSY",
      "code_information": [
        {
          "code": "3600357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 98.9858,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 14-16FR",
      "code_information": [
        {
          "code": "3600358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 178,
          "minimum": 60.8519,
          "maximum": 755.1838,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-ION SWIVEL",
      "code_information": [
        {
          "code": "3600359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1358,
          "minimum": 464.2525,
          "maximum": 22602.1284,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 5X356/126MM 03.008.008",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 580.0123,
          "maximum": 1394.0697,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 975.8488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROC 2.3X230 P99-194-2323",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 958.1603,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 509.514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
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        {
          "code": "3600412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 691.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUMIDIFIER-CPAP HC325S",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 444.88,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 73.1506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE M001141006",
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        {
          "code": "3600430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1293,
          "minimum": 442.0313,
          "maximum": 3176.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 656.8311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-2-2.7MM 706200",
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        {
          "code": "3600436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 716.2659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-8MM/SD LORD 1088-43-008",
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        {
          "code": "3600449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2006.0525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER FLX 4150016000",
      "code_information": [
        {
          "code": "3600467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4998,
          "minimum": 1708.6406,
          "maximum": 9651.6716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2538.934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-9X250 STP 4150002090",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 10446.8946,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1104.8782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-FETAL C-SECTION",
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        {
          "code": "3600474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5613,
          "minimum": 546.0902,
          "maximum": 4073.3541,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2851.3479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-BAND POLY CFI-733",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 1676.0854,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 39.6232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PUMP 8\\\" AR-6411",
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        {
          "code": "3600498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 261.5266,
          "maximum": 555.1605,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 388.6123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC OUTFLOW AR-6435",
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        {
          "code": "3600499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 752,
          "minimum": 257.0824,
          "maximum": 2799.9635,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY M00516071",
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        {
          "code": "3600502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 73.1591,
          "maximum": 820.8036,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VEIN HARVEST VASOVIEW",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 207.4253,
          "maximum": 1071.1332,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 749.7932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURSPLEX DART300 NASAL",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 26.6655,
          "maximum": 77.854,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 39.6232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURAPLEX DART-REACH600",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 47.8611,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY O40-403",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 142.8995,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 4.6X340 P99-110-4634",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 207.4253,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1421.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 11X200 4922-8-200",
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          "code": "3600545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 610.5706,
          "maximum": 1296.1002,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 907.2701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HEMOCON PERF 020271801",
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        {
          "code": "3600548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 842,
          "minimum": 287.8502,
          "maximum": 5717.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 427.7276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-SINGLE NEOPRENE M8138",
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        {
          "code": "3600550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 47.2685,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION ADULT",
      "code_information": [
        {
          "code": "3600551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 29.0585,
          "maximum": 61.6845,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION PED",
      "code_information": [
        {
          "code": "3600552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 68.4003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383592",
      "code_information": [
        {
          "code": "3600553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 123,
          "minimum": 42.0494,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.4828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG STRT AR-7821",
      "code_information": [
        {
          "code": "3600561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 843.7714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 10FL AR-9280NOT",
      "code_information": [
        {
          "code": "3600562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 378.7863,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-NANO 2.8X11 AR-9280NSR",
      "code_information": [
        {
          "code": "3600563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 378.7863,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.8529,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-HP EVAC 70 E1CA5874-01",
      "code_information": [
        {
          "code": "3600565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2197,
          "minimum": 751.0771,
          "maximum": 1594.3629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1116.054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-EVAC 70 EICA5872-01",
      "code_information": [
        {
          "code": "3600567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2097,
          "minimum": 716.8906,
          "maximum": 1521.7929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1065.255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE XP EICA8872-01",
      "code_information": [
        {
          "code": "3600568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2093,
          "minimum": 715.5232,
          "maximum": 8030.6401,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1063.2231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PURPLE",
      "code_information": [
        {
          "code": "3600570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY PURPLE",
      "code_information": [
        {
          "code": "3600571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PINK/RED",
      "code_information": [
        {
          "code": "3600574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY YELLOW",
      "code_information": [
        {
          "code": "3600575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 173.4423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY WHITE",
      "code_information": [
        {
          "code": "3600576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION WHITE",
      "code_information": [
        {
          "code": "3600577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION BLUE",
      "code_information": [
        {
          "code": "3600579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION ORANGE",
      "code_information": [
        {
          "code": "3600580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY ORANGE",
      "code_information": [
        {
          "code": "3600581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 272.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION GREEN",
      "code_information": [
        {
          "code": "3600582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 132.9079,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 455.4459,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.4096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GUIDE 95CM/9FR STRT",
      "code_information": [
        {
          "code": "3600599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 968.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 16MM P45-914-0001",
      "code_information": [
        {
          "code": "3600607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-XL 10MM HEX P45-941-0001",
      "code_information": [
        {
          "code": "3600609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 345.9412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT P45-170-1000",
      "code_information": [
        {
          "code": "3600610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 870.8526,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3431.9804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MEASURE STOMA MIC-KEY",
      "code_information": [
        {
          "code": "3600617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.2271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENTERAL FEEDING LITE",
      "code_information": [
        {
          "code": "3600618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 100.1466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.1026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-FARREL ENTERAL W BAG",
      "code_information": [
        {
          "code": "3600619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 786.8815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.7MM AR-7511",
      "code_information": [
        {
          "code": "3600664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 901.4381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 WHITE 48360W",
      "code_information": [
        {
          "code": "3600665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 823.4518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLUE 48360B",
      "code_information": [
        {
          "code": "3600666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 823.4518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 GREEN 48360G",
      "code_information": [
        {
          "code": "3600667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 823.4518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLACK 48360T",
      "code_information": [
        {
          "code": "3600668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1621,
          "minimum": 554.1629,
          "maximum": 1176.3597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 823.4518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-PORTABLE DEVILBISS",
      "code_information": [
        {
          "code": "3600669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2011,
          "minimum": 32.2538,
          "maximum": 1459.3827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1021.5679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WATER-STERILE INHALATION 500ML",
      "code_information": [
        {
          "code": "3600670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 1121.0976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-14FR SU130-1239",
      "code_information": [
        {
          "code": "3600671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2016,
          "minimum": 689.1996,
          "maximum": 1463.0112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1024.1078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-16FR SU130-1240",
      "code_information": [
        {
          "code": "3600672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2016,
          "minimum": 689.1996,
          "maximum": 6323.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1024.1078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-12mm 47050",
      "code_information": [
        {
          "code": "3600674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 333.66,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X185MM 2351-4218S",
      "code_information": [
        {
          "code": "3600681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 660.387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 1.7MM DSDS0017",
      "code_information": [
        {
          "code": "3600688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 968.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2MM DSDS0020",
      "code_information": [
        {
          "code": "3600689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 272.489,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 968.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3600708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1042,
          "minimum": 356.2232,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 529.3256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.6X150MM AR-8741-16",
      "code_information": [
        {
          "code": "3600710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 209.905,
          "maximum": 1371.8987,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 311.9059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,-TR 2X8MM AR-300-B002",
      "code_information": [
        {
          "code": "3600711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 1790.3019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1253.2113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION AR-200",
      "code_information": [
        {
          "code": "3600717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 200.1481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-3.7MM DRILL AR-2272",
      "code_information": [
        {
          "code": "3600719",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1425,
          "minimum": 487.1574,
          "maximum": 4598.3909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 723.8857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO POLY M-L 51114V",
      "code_information": [
        {
          "code": "3600722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 93.4248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.6232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.102",
      "code_information": [
        {
          "code": "3600736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 25181.3202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 525.7696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 X806H",
      "code_information": [
        {
          "code": "3600739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 4854.1969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN PVC 24FR",
      "code_information": [
        {
          "code": "3600749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 746.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.0513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANCHOR-ENTUIT SUTURE G35562",
      "code_information": [
        {
          "code": "3600750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1342,
          "minimum": 431.5336,
          "maximum": 973.8894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 681.7226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LEAD-CATH 4FR 38 383069",
      "code_information": [
        {
          "code": "3600757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 23820.5435,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1346.6815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-NITINOL 2.0MM",
      "code_information": [
        {
          "code": "3600759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6MM MXM-072-16",
      "code_information": [
        {
          "code": "3600767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 913.874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6 MXM-072-ISO-16",
      "code_information": [
        {
          "code": "3600768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 913.874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RCC RMH-T015S",
      "code_information": [
        {
          "code": "3600773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 904,
          "minimum": 309.0458,
          "maximum": 3144.7455,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXOFIN FUSION EF70430",
      "code_information": [
        {
          "code": "3600781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 976,
          "minimum": 62.2832,
          "maximum": 708.2832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 495.7982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 MONOTEX FS-2 T8665",
      "code_information": [
        {
          "code": "3600782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 300.294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA",
      "code_information": [
        {
          "code": "3600783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 274.3146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "XTRAFLANGE-PROVOX 20 FR 7276",
      "code_information": [
        {
          "code": "3600784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 1084.9511,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 274.3146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20 FR 6MM 8277",
      "code_information": [
        {
          "code": "3600785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1951,
          "minimum": 666.9783,
          "maximum": 1622.6998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 991.0885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2006-NS",
      "code_information": [
        {
          "code": "3600786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-NS",
      "code_information": [
        {
          "code": "3600787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7FR 4",
      "code_information": [
        {
          "code": "3600789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7F 34",
      "code_information": [
        {
          "code": "3600790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 722.93,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE 4.2X130 2351-4213S",
      "code_information": [
        {
          "code": "3600791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 660.387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-LOCK 4.2X360 2351-4236S",
      "code_information": [
        {
          "code": "3600792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 444.4243,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 660.387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-CARDIOTOMY EL400",
      "code_information": [
        {
          "code": "3600858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 579,
          "minimum": 197.9398,
          "maximum": 670.6566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 294.1262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 34CC LINEAR",
      "code_information": [
        {
          "code": "3600866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4523,
          "minimum": 1546.2548,
          "maximum": 3282.3411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2297.6388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 40CC MEGA 0",
      "code_information": [
        {
          "code": "3600867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4905,
          "minimum": 1676.8471,
          "maximum": 3559.5585,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2491.6909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 50CC MEGA 0",
      "code_information": [
        {
          "code": "3600868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4905,
          "minimum": 1676.8471,
          "maximum": 3559.5585,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2491.6909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-8\\\" THD AR-8967KT",
      "code_information": [
        {
          "code": "3600879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 836.3744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 194.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1 LMA",
      "code_information": [
        {
          "code": "3600899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.6552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-STR 4MM P1-AU511",
      "code_information": [
        {
          "code": "3600906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7067,
          "minimum": 45.6002,
          "maximum": 5128.5219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3589.9653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1.5 LMA",
      "code_information": [
        {
          "code": "3600907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 59.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.6552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 3 LMA",
      "code_information": [
        {
          "code": "3600908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 5 LMA",
      "code_information": [
        {
          "code": "3600909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 52.9761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 2 LMA",
      "code_information": [
        {
          "code": "3600910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS MED TRACTION",
      "code_information": [
        {
          "code": "3600912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS LG TRACTION",
      "code_information": [
        {
          "code": "3600913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS SM TRACTION",
      "code_information": [
        {
          "code": "3600914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 64.5076,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 130187",
      "code_information": [
        {
          "code": "3600915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 6163.2563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SHRT SCREW 6149.1042",
      "code_information": [
        {
          "code": "3600925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EZX 54MM BRXTB540",
      "code_information": [
        {
          "code": "3600938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5636,
          "minimum": 1926.7504,
          "maximum": 6657.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2863.0316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX 45MM 227445500",
      "code_information": [
        {
          "code": "3600946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1795.0908,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-TOGA XL 0416-830-100",
      "code_information": [
        {
          "code": "3600948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 909,
          "minimum": 310.7552,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 461.7629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20F 10MM 8279",
      "code_information": [
        {
          "code": "3600952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1894,
          "minimum": 647.492,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 962.1331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS MALLEABLE 4MM",
      "code_information": [
        {
          "code": "3600954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 9196.7818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1104.8782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG LIGHT MED C02051",
      "code_information": [
        {
          "code": "3600964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 79.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG SMALL C020500",
      "code_information": [
        {
          "code": "3600965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 1673.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 228MM 56010228",
      "code_information": [
        {
          "code": "3600977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-JONES 3.2MM 56013200",
      "code_information": [
        {
          "code": "3600978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 968.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 5.5MM 56015500",
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        {
          "code": "3600980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1584,
          "minimum": 541.5139,
          "maximum": 4020.603,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 804.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CRYOTHERAPY FGS-7000",
      "code_information": [
        {
          "code": "3600997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5867,
          "minimum": 75.0735,
          "maximum": 4257.6819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2980.3773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXHAUST COLLECT FGS-7015",
      "code_information": [
        {
          "code": "3600999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONN-X 5.5/32-40 LNG 1119.0034",
      "code_information": [
        {
          "code": "3601000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 1089.8652,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1619.4721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PREP 4.2MM 0909-100-042",
      "code_information": [
        {
          "code": "3601029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EXP 4.2MM 0909-200-042",
      "code_information": [
        {
          "code": "3601030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 389.27,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ XF 4.2MM 0909-400-400",
      "code_information": [
        {
          "code": "3601031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 700,
          "minimum": 239.3054,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 355.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 10MM 650.110",
      "code_information": [
        {
          "code": "3601032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CRV 4MM P1-AU550",
      "code_information": [
        {
          "code": "3601055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 2690.4764,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3997.8813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-360-430 ALLOX2-FH13SE",
      "code_information": [
        {
          "code": "3601056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7446,
          "minimum": 207.4253,
          "maximum": 5403.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3782.4935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACENTESIS/PARACENTESI",
      "code_information": [
        {
          "code": "3601066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 701,
          "minimum": 226.3327,
          "maximum": 508.7157,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 356.101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G CMNT 0306-150-000",
      "code_information": [
        {
          "code": "3601086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 598,
          "minimum": 204.4352,
          "maximum": 433.9686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CMNT 11G 0306-330-000",
      "code_information": [
        {
          "code": "3601087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 642,
          "minimum": 219.4772,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 326.1296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TB AR-200",
      "code_information": [
        {
          "code": "3601096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 206.2439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRILL 3X320 P31-951-3032",
      "code_information": [
        {
          "code": "3601107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1963,
          "minimum": 671.0807,
          "maximum": 1556.5239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 997.1844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 7X200 P99-110-7019",
      "code_information": [
        {
          "code": "3601108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1421.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-110-4630",
      "code_information": [
        {
          "code": "3601109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1421.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.8X250 P99-100-3825",
      "code_information": [
        {
          "code": "3601110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 956.8797,
          "maximum": 2031.2343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1421.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-16 HLW 03.037.004S",
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        {
          "code": "3601121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CENTRAL VENOUS PED",
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        {
          "code": "3601123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 669,
          "minimum": 194.635,
          "maximum": 485.4933,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 339.8453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOD-PROTECTOR 69392",
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        {
          "code": "3601124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 350,
          "minimum": 119.6527,
          "maximum": 253.995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.7965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT ADULT DISP 731",
      "code_information": [
        {
          "code": "3601125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 273,
          "minimum": 93.3291,
          "maximum": 198.1161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.6813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-VARISPEED 62-50201",
      "code_information": [
        {
          "code": "3601154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1913,
          "minimum": 653.9875,
          "maximum": 1388.2641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 971.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.5MM 72202189",
      "code_information": [
        {
          "code": "3601200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1735.5881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 583.6805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STR 14MM/SC 684.424",
      "code_information": [
        {
          "code": "3601216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2509.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SUCTION BALLARD 14FR",
      "code_information": [
        {
          "code": "3601234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 952.0432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.5786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 35FR 412351000",
      "code_information": [
        {
          "code": "3601235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 869.6789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 37FR 412371000",
      "code_information": [
        {
          "code": "3601236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 886.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 39FR 412391000",
      "code_information": [
        {
          "code": "3601237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 886.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER MD 4934-8-140",
      "code_information": [
        {
          "code": "3601242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-1.8X450 DIA PT 4933-8-010",
      "code_information": [
        {
          "code": "3601244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 682,
          "minimum": 233.1518,
          "maximum": 494.9274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 346.4492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 120MM 4933-1-120",
      "code_information": [
        {
          "code": "3601245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 527,
          "minimum": 180.1628,
          "maximum": 382.4439,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 267.7107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SCREW 6149.1040",
      "code_information": [
        {
          "code": "3601255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 42686.7921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-IV SW 3000ML BAG S8505",
      "code_information": [
        {
          "code": "3601260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 22040.4674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4MM CANN AR-8973-40S",
      "code_information": [
        {
          "code": "3601272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 793.4804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-PIN & PROT P45-610-1000",
      "code_information": [
        {
          "code": "3601289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 1074.9413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 210.8158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-10MM P47-950-0001",
      "code_information": [
        {
          "code": "3601290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1933,
          "minimum": 115.6688,
          "maximum": 1402.7781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-PROTECT P45-600-1000-S",
      "code_information": [
        {
          "code": "3601291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 298.6257,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.6619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-AIR+MENISCAL CV 4722",
      "code_information": [
        {
          "code": "3601324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2551,
          "minimum": 870.8526,
          "maximum": 1851.2607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1295.8825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-GRAFT LG M00236320021",
      "code_information": [
        {
          "code": "3601349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 176,
          "minimum": 60.1682,
          "maximum": 157.3763,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.4062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC SMALL 313-9013W",
      "code_information": [
        {
          "code": "3601350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.7612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC MED 313-9014W",
      "code_information": [
        {
          "code": "3601351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 205.3731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.7612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-2.5 PRCSN MTCH HD 16CM",
      "code_information": [
        {
          "code": "3601354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1891,
          "minimum": 646.4665,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 960.6091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROCH 1.1MM AR-18700-30",
      "code_information": [
        {
          "code": "3601375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STEP SOLID 1806-3026S",
      "code_information": [
        {
          "code": "3601387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1432,
          "minimum": 489.5505,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 727.4417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47522",
      "code_information": [
        {
          "code": "3601390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 909.3021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 636.5115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOCLOT EPK2303-01",
      "code_information": [
        {
          "code": "3601392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 329.2112,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-ENDOCLOT EA230",
      "code_information": [
        {
          "code": "3601393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 592,
          "minimum": 202.384,
          "maximum": 11794.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 300.7301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 12\\\" 3.2MM",
      "code_information": [
        {
          "code": "3601397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 399,
          "minimum": 136.4041,
          "maximum": 5711.147,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 202.688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.25MM  AR-18800-35",
      "code_information": [
        {
          "code": "3601403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 851,
          "minimum": 290.927,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 432.2995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-10X16X8/12° 1213.6088S",
      "code_information": [
        {
          "code": "3601406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6769,
          "minimum": 2314.0832,
          "maximum": 4912.2633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3438.5843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 16X8MM 1128.2408",
      "code_information": [
        {
          "code": "3601407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 580.5684,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2292.5589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X14MM 184.014",
      "code_information": [
        {
          "code": "3601408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X16MM 184.016",
      "code_information": [
        {
          "code": "3601409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR SD 4.2X14MM 184.054",
      "code_information": [
        {
          "code": "3601410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-KANGAROO Y-PORT/PEG",
      "code_information": [
        {
          "code": "3601419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 58.056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 18FR 8887605189",
      "code_information": [
        {
          "code": "3601420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 20FR 8887605205",
      "code_information": [
        {
          "code": "3601421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 3586.2889,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IN/OUTFLOW AR-6436",
      "code_information": [
        {
          "code": "3601433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1031,
          "minimum": 352.4627,
          "maximum": 748.1967,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 523.7377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 614,
          "minimum": 53.9417,
          "maximum": 445.5798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 311.9059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G-TUBE ENFIT",
      "code_information": [
        {
          "code": "3601440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1234,
          "minimum": 392.6066,
          "maximum": 895.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 626.8597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG ENFIT 24FR M00509061",
      "code_information": [
        {
          "code": "3601441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 706,
          "minimum": 241.3566,
          "maximum": 512.3442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 358.6409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5020",
      "code_information": [
        {
          "code": "3601445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 846,
          "minimum": 60.0588,
          "maximum": 613.9422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 429.7595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOCKWAVE STERILE CABLE",
      "code_information": [
        {
          "code": "3601446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 84.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16FR 20CM G01212",
      "code_information": [
        {
          "code": "3601447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.2145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-18FR 20CM G01328",
      "code_information": [
        {
          "code": "3601448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.2145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO JEJUNAL 8250-22",
      "code_information": [
        {
          "code": "3601452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1577,
          "minimum": 539.1209,
          "maximum": 1144.4289,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 801.1002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 8200-20",
      "code_information": [
        {
          "code": "3601453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 246.9084,
          "maximum": 1004.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 703.0582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10FR 50-7361",
      "code_information": [
        {
          "code": "3601454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 444,
          "minimum": 151.788,
          "maximum": 544.978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 225.5476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 18140",
      "code_information": [
        {
          "code": "3601455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 711.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 497.8302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DLP CORONARY 30315",
      "code_information": [
        {
          "code": "3601479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 510,
          "minimum": 174.3511,
          "maximum": 486.5875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 259.0749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 875,
          "minimum": 53.9417,
          "maximum": 634.9875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 444.4912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 14FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC DRG MN12050",
      "code_information": [
        {
          "code": "3601484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 42051.7259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1363.9531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PREFORM-S3-4 39+6MM DWP2396",
      "code_information": [
        {
          "code": "3601576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8123,
          "minimum": 2509.6793,
          "maximum": 5894.8611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4126.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 18X7MM 1128.1507",
      "code_information": [
        {
          "code": "3601577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 1542.8361,
          "maximum": 17566.6429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2292.5589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-20X55 8-17 5° 1122.1055",
      "code_information": [
        {
          "code": "3601578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 31589,
          "minimum": 870.8526,
          "maximum": 22924.1373,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 16046.8961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 3X14 AR-8630-14",
      "code_information": [
        {
          "code": "3601580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1056.1112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 2.5X16 AR-8625-16",
      "code_information": [
        {
          "code": "3601581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 670.6566,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1056.1112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LP/CRT 1.6X9 AR-18716-09",
      "code_information": [
        {
          "code": "3601582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1206,
          "minimum": 230.7815,
          "maximum": 875.1942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 612.6359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CABLE PLATE 94-1200-08",
      "code_information": [
        {
          "code": "3601588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5867,
          "minimum": 2005.7211,
          "maximum": 4257.6819,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2980.3773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AUX CBL PLT 94-1500-04-S",
      "code_information": [
        {
          "code": "3601589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 534.4121,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1195",
      "code_information": [
        {
          "code": "3601590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 836.3744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 488.1784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ1 CN P2ND1001",
      "code_information": [
        {
          "code": "3601591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 514.1647,
          "maximum": 4843.631,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 764.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-PEDI DSG P2HE2000",
      "code_information": [
        {
          "code": "3601592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8710,
          "minimum": 870.8526,
          "maximum": 6320.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4424.5929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BALLARD/NEO BAA2103",
      "code_information": [
        {
          "code": "3601615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 54.0146,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.2624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-DF 65MM/RT/STD 6495-2-040",
      "code_information": [
        {
          "code": "3601630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21681,
          "minimum": 1548.1824,
          "maximum": 15733.9017,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11013.7312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CN/CC 7X45MM 8040-045",
      "code_information": [
        {
          "code": "3601631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 497.7095,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1414.2442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-SMALL KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7523,
          "minimum": 2571.8493,
          "maximum": 5459.4411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3821.6088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-LARGE KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7523,
          "minimum": 1795.0908,
          "maximum": 5459.4411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3821.6088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-WOUND CROWN",
      "code_information": [
        {
          "code": "3601647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 571.8516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 400.2961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN RAL 6MM B02236010",
      "code_information": [
        {
          "code": "3601652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 1826.5869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1278.6108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN STD 6MM B02236001",
      "code_information": [
        {
          "code": "3601653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 7992.8253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1278.6108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL LK 3.5 AR-8943-43",
      "code_information": [
        {
          "code": "3601667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 2352.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1360.3972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ALEXIS M/L HR105",
      "code_information": [
        {
          "code": "3601692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 886.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5 SHORT 6149.1038S",
      "code_information": [
        {
          "code": "3601700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLEY-COUVEL 3-W",
      "code_information": [
        {
          "code": "3601705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 99.5419,
          "maximum": 216.9843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-O3 OXIMETRY CEREBRAL",
      "code_information": [
        {
          "code": "3601707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM",
      "code_information": [
        {
          "code": "3601709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 929.1887,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1380.7168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM BOX",
      "code_information": [
        {
          "code": "3601710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2537,
          "minimum": 165.7178,
          "maximum": 1841.1009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1288.7706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 23/M P01-900-2303",
      "code_information": [
        {
          "code": "3601722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 4555.0151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1374.1129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ2 CN P2ND1002",
      "code_information": [
        {
          "code": "3601743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1504,
          "minimum": 514.1647,
          "maximum": 1091.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 764.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 16FR",
      "code_information": [
        {
          "code": "3601752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 980,
          "minimum": 335.0276,
          "maximum": 2180.4681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 497.8302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-DEBRIDEMENT DDBK02",
      "code_information": [
        {
          "code": "3601755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4392.0778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CV/XS 4MM P1-AU551",
      "code_information": [
        {
          "code": "3601759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 2690.4764,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3997.8813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 3/10F AR-98300OBT",
      "code_information": [
        {
          "code": "3601764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 827,
          "minimum": 282.7222,
          "maximum": 600.1539,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 420.1077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CIR/BEV P45-940-1001",
      "code_information": [
        {
          "code": "3601766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 5151.7104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 113.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FLIPCUTTER III AR-1204FF",
      "code_information": [
        {
          "code": "3601777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2543,
          "minimum": 869.3623,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MGS 3MM AR-9628S",
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        {
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1508.7303,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-INFANT NEONATE CO2",
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        {
          "code": "3601783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCAN 4MM AR-1204D",
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        {
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1261,
          "minimum": 431.0916,
          "maximum": 1371.8987,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "DRILL-.066CN 2.75MM AR-7000-14",
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          "code": "0270",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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      "service_type": "CDM"
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        {
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          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      "service_type": "CDM"
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    {
      "description": "WIRE-GUIDE .062X7\\\" AR-8941-7",
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 171.6162,
          "maximum": 923.6821,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG ST TR AR-7823",
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        {
          "code": "0270",
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        {
          "setting": "inpatient",
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          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 843.7714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JTIP 8164-2001-25",
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        {
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          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 25.9817,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRAY AR-200SP",
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          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
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          "minimum": 676.8924,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "WIRE-G MIS SHARP 501168",
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        {
          "code": "3601880",
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          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 204.0933,
          "maximum": 2801.6318,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE 6MM BH-220",
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        {
          "code": "3601882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11846,
          "minimum": 1735.5881,
          "maximum": 8596.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 6017.6495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMAN.157X9\\\" KI71675",
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          "type": "LOCAL"
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 31.6977,
          "maximum": 140.0601,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .035X9\\\" DD KI71211",
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        {
          "code": "3601894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 7509.5744,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FRACTURE KEX152EB",
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        {
          "code": "3601895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 13504,
          "minimum": 870.8526,
          "maximum": 9799.8528,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 6859.897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-TIB 11X360MM 1822-1136S",
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          "code": "3601898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5142,
          "minimum": 1757.8691,
          "maximum": 10766.096,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2612.0846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LASER TRACH #5 102004050",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 425.6218,
          "maximum": 1157.2441,
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            {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-BLOOD COLLECT 04258",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 199.9909,
          "maximum": 424.5345,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77720",
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          "code": "3601934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 254.3475,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "WIRE-C TR TIP .062X5\\\" 5050-249",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 48.8867,
          "maximum": 103.7751,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLUTION-WOUND VASHE 16OZ 003",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 106.6618,
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            {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX944",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 95.0384,
          "maximum": 7214.8414,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "COUNTERSINK-4MM AO 702473",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 728.514,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "code": "3601961",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 589.0332,
          "maximum": 1746.7101,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 400MM BT 693.060S",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 179.4791,
          "maximum": 1399.7037,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 266.6947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM 1032-115-000",
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        {
          "code": "3601985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10370,
          "minimum": 3545.1386,
          "maximum": 11179.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM 2PROBE 9700-020-200",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
          "gross_charge": 20104,
          "minimum": 265.8158,
          "maximum": 14589.4728,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 10212.631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-AEOS STERILE PV012SU",
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          "code": "3601989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 462,
          "minimum": 157.9416,
          "maximum": 335.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 234.6914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA 22FR 77422",
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        {
          "code": "3601990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 191.1025,
          "maximum": 1175.5954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 283.9664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ENDO 5MM 174209",
      "code_information": [
        {
          "code": "3601996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1819,
          "minimum": 464.8996,
          "maximum": 1320.0483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 924.0338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 6213-119-070",
      "code_information": [
        {
          "code": "3601997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 194.0789,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.6796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PURESOME TMD-07",
      "code_information": [
        {
          "code": "3601998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 349,
          "minimum": 99.5419,
          "maximum": 253.2693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.2885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM AR-8943-36",
      "code_information": [
        {
          "code": "3602028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1198,
          "minimum": 409.5541,
          "maximum": 869.3886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 608.572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PED LUMBAR 21G 645",
      "code_information": [
        {
          "code": "3602032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 219,
          "minimum": 74.8684,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.2498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X C/D",
      "code_information": [
        {
          "code": "3602043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X C/D",
      "code_information": [
        {
          "code": "3602044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 209.0016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 146.3011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X C/D",
      "code_information": [
        {
          "code": "3602045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL C/D",
      "code_information": [
        {
          "code": "3602046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG C/D",
      "code_information": [
        {
          "code": "3602047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED C/D",
      "code_information": [
        {
          "code": "3602048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K SMALL C/D",
      "code_information": [
        {
          "code": "3602049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X A/B",
      "code_information": [
        {
          "code": "3602050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X A/B",
      "code_information": [
        {
          "code": "3602051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X A/B",
      "code_information": [
        {
          "code": "3602052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 288,
          "minimum": 98.4571,
          "maximum": 209.0016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 146.3011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL A/B",
      "code_information": [
        {
          "code": "3602053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG A/B",
      "code_information": [
        {
          "code": "3602054",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN CMP 2.2 DSDS0022",
      "code_information": [
        {
          "code": "3602079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1906,
          "minimum": 651.5944,
          "maximum": 1383.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 968.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-JOINT PREP INST 9914PK01",
      "code_information": [
        {
          "code": "3602083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 418.1872,
          "maximum": 1704.6693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1193.2685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP 1.1 NT/SM 58820006",
      "code_information": [
        {
          "code": "3602084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 752,
          "minimum": 257.0824,
          "maximum": 1541.5092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 382.0085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MICA 2X12MM 57SR0212",
      "code_information": [
        {
          "code": "3602085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2772,
          "minimum": 947.6494,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1408.1483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MICA INST BLADE 57S1MI07",
      "code_information": [
        {
          "code": "3602088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2242,
          "minimum": 766.461,
          "maximum": 1627.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1138.9136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAMPATNCY FGS-0668",
      "code_information": [
        {
          "code": "3602103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 194.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRUDI SHAVER TSB4STR",
      "code_information": [
        {
          "code": "3602104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 497.7095,
          "maximum": 2313.5316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1619.4721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-BIENAIR AQUACARE 1600617",
      "code_information": [
        {
          "code": "3602106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 145.1421,
          "maximum": 433.2429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-OSTOMY 18665",
      "code_information": [
        {
          "code": "3602109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-CLOSED TUBE 1320-0125S",
      "code_information": [
        {
          "code": "3602113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 959,
          "minimum": 327.8484,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 487.1624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 724G",
      "code_information": [
        {
          "code": "3602121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 52.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0 8756H",
      "code_information": [
        {
          "code": "3602122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 7.7854,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0   8717H",
      "code_information": [
        {
          "code": "3602124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 71.4498,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 106.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-EVARREST 2x4\\\" EVT5024",
      "code_information": [
        {
          "code": "3602126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4700,
          "minimum": 1606.7648,
          "maximum": 3410.79,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2387.553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-6 LEAD ECG SNAP BR-916PA",
      "code_information": [
        {
          "code": "3602128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1080,
          "minimum": 369.214,
          "maximum": 783.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 548.6292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TRI 4.0MM P1-AU411",
      "code_information": [
        {
          "code": "3602153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7067,
          "minimum": 207.4253,
          "maximum": 5128.5219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3589.9653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602172",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 886.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602176",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.3112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1056.1112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
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        {
          "code": "3602179",
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1414.2442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
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        {
          "code": "3602191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 582.1565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 C012D",
      "code_information": [
        {
          "code": "3602196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 190.7423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 843.7714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 3788.7093,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2046.1837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 886.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.3112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 696.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1056.1112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1414.2442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 582.1565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-FENSTRATION 58FENAWL",
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        {
          "code": "3602253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3164,
          "minimum": 1081.6604,
          "maximum": 2296.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1607.2804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 2923.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2046.1837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
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        {
          "code": "3602265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 843.7714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
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        {
          "code": "3602266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 6764.9565,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-END +5 HUM 1830-0005S",
      "code_information": [
        {
          "code": "3602288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1128,
          "minimum": 385.6236,
          "maximum": 1795.0908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 573.0127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 886.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.3112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 994.9347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2785,
          "minimum": 952.0936,
          "maximum": 2021.0745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1414.7521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 582.1565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT DL 15MM PROBE 9700-015-200",
      "code_information": [
        {
          "code": "3602331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 22350,
          "minimum": 870.8526,
          "maximum": 16219.395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11353.5765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 637.2906,
          "maximum": 2923.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2046.1837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3164,
          "minimum": 1081.6604,
          "maximum": 2296.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1607.2804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2185,
          "minimum": 746.9747,
          "maximum": 5893.5478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1109.9581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4028,
          "minimum": 1377.0317,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2046.1837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1661,
          "minimum": 567.8375,
          "maximum": 1205.3877,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 843.7714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 2104.8385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1745,
          "minimum": 596.5542,
          "maximum": 1266.3465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 886.4425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 1010.4337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 583.6805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 762.4131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.3112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 1156.1319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 1548.1824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1056.1112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2784,
          "minimum": 951.7518,
          "maximum": 2020.3488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1414.2442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1098.2975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 582.1565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT 125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 3017.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5426,
          "minimum": 1854.9587,
          "maximum": 3937.6482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2756.3537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2185,
          "minimum": 746.9747,
          "maximum": 3017.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1109.9581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5426,
          "minimum": 580.5684,
          "maximum": 3937.6482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2756.3537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 13MM 7786713",
      "code_information": [
        {
          "code": "3602404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 7786703",
      "code_information": [
        {
          "code": "3602405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-MDI SPACER M 1082715",
      "code_information": [
        {
          "code": "3602410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 136.2445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.3389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRXPERION XP65/115VS",
      "code_information": [
        {
          "code": "3602411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 245,
          "minimum": 83.7569,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 124.4575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH SZ5/90MM A0A14",
      "code_information": [
        {
          "code": "3602422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 2737.1242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON LINEAR 40",
      "code_information": [
        {
          "code": "3602462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5202,
          "minimum": 99.5419,
          "maximum": 3775.0914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2642.564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 111331",
      "code_information": [
        {
          "code": "3602483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 966,
          "minimum": 330.2415,
          "maximum": 1123.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 490.7183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SKIN CLOSURE CLR602US",
      "code_information": [
        {
          "code": "3602486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1556,
          "minimum": 531.9417,
          "maximum": 1129.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 790.4324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-RADIAN FACET K 5526061",
      "code_information": [
        {
          "code": "3602487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1514,
          "minimum": 517.5834,
          "maximum": 1098.7098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 769.0969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 11MM 7786711",
      "code_information": [
        {
          "code": "3602491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PELVIC STAB T-PODR",
      "code_information": [
        {
          "code": "3602497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 319.6436,
          "maximum": 5019.3586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 474.9706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIR-G BL-NOSE 3X900 0101-900S",
      "code_information": [
        {
          "code": "3602503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 981.5165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 636.5115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165MM S0210-200",
      "code_information": [
        {
          "code": "3602508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1940,
          "minimum": 663.2178,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 985.5006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OPEN REAMER 03.168.004",
      "code_information": [
        {
          "code": "3602515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 8067,
          "minimum": 1758.9443,
          "maximum": 5854.2219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4097.9553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3X413MM 03.168.011",
      "code_information": [
        {
          "code": "3602516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3163,
          "minimum": 1079.9462,
          "maximum": 2295.3891,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1606.7724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LOWER 8/+0 END 2330-0000S",
      "code_information": [
        {
          "code": "3602538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1299,
          "minimum": 444.0825,
          "maximum": 942.6843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 659.879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEART LOOP AV 9S44R",
      "code_information": [
        {
          "code": "3602540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 525,
          "minimum": 179.4791,
          "maximum": 3726.9822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 266.6947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-LOW PROFILE 6143.2527",
      "code_information": [
        {
          "code": "3602541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6702,
          "minimum": 2249.4245,
          "maximum": 4863.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3404.549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 160MM P45-180-0160",
      "code_information": [
        {
          "code": "3602542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4045,
          "minimum": 1382.8434,
          "maximum": 3757.0116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2054.8195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 160MM P45-112-0140",
      "code_information": [
        {
          "code": "3602543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 1091.6243,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3431.9804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-G BALL 3X550 P31-955-1550",
      "code_information": [
        {
          "code": "3602544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1963,
          "minimum": 610.0417,
          "maximum": 1424.5491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 997.1844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-300MM THRED P45-310-0300",
      "code_information": [
        {
          "code": "3602545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 3455.6054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.265,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRUTS-QA MOD MD P45-224-0170",
      "code_information": [
        {
          "code": "3602546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6214,
          "minimum": 870.8526,
          "maximum": 4509.4998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3156.6499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KET-ENDO BSC CEK-924-20",
      "code_information": [
        {
          "code": "3602548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 13697.2991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.7578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INST ARAGONITE MINI-DS",
      "code_information": [
        {
          "code": "3602550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 13194.0286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1023.0919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOINT-BALL MOD P45-233-1000",
      "code_information": [
        {
          "code": "3602557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1687.5428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE 1.8 P99-202-1810",
      "code_information": [
        {
          "code": "3602569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1065,
          "minimum": 207.4253,
          "maximum": 772.8705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 541.0093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCPP41D",
      "code_information": [
        {
          "code": "3602572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.9462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PRONE LAT STAB 6246.0200",
      "code_information": [
        {
          "code": "3602576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7446,
          "minimum": 2545.5257,
          "maximum": 5403.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3782.4935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TT 2.4X9.25 AR-8870K",
      "code_information": [
        {
          "code": "3602593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 235,
          "minimum": 80.3382,
          "maximum": 900.3259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 119.3776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT W/CAP",
      "code_information": [
        {
          "code": "3602596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.8192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT 205-212",
      "code_information": [
        {
          "code": "3602597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT WAVE+ 3.9M",
      "code_information": [
        {
          "code": "3602598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2435.812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT FLEX 2.9MM",
      "code_information": [
        {
          "code": "3602599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4513,
          "minimum": 1542.8361,
          "maximum": 3275.0841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2292.5589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT SMOL 2.9MM",
      "code_information": [
        {
          "code": "3602600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3012,
          "minimum": 870.8526,
          "maximum": 2185.8084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1530.0659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3602604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4897,
          "minimum": 1674.1122,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2487.627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3602606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4897,
          "minimum": 1674.1122,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2487.627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.2L CN AR-8973-32LS",
      "code_information": [
        {
          "code": "3602614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 4355.9313,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 793.4804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°RT AR-4068-90R",
      "code_information": [
        {
          "code": "3602617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 742.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°LT AR-4068-90L",
      "code_information": [
        {
          "code": "3602618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 524.7626,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 779.7646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°LT AR-4068-45L",
      "code_information": [
        {
          "code": "3602619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 524.7626,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 779.7646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°RT AR-4068-45R",
      "code_information": [
        {
          "code": "3602620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1535,
          "minimum": 222.9961,
          "maximum": 1113.9495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 779.7646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPLEDAM AR-6530TD",
      "code_information": [
        {
          "code": "3602621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 203.704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DTRAX SPINAL DX-22-300",
      "code_information": [
        {
          "code": "3602622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 870.8526,
          "maximum": 3684.3789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2579.0652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS 11G/5\\\"\\\" 0306-116-000",
      "code_information": [
        {
          "code": "3602624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 774,
          "minimum": 264.6034,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 393.1843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-GUIDE VDR 80-0049",
      "code_information": [
        {
          "code": "3602651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1847.3642,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-OPTIFIX ABSORB 0113126",
      "code_information": [
        {
          "code": "3602652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1687.5428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 14FR G00996",
      "code_information": [
        {
          "code": "3602678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 145,
          "minimum": 49.5704,
          "maximum": 105.2265,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 12FR G00995",
      "code_information": [
        {
          "code": "3602679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 3513.4398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.2145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-MWCE-18S-4/2-TORNADO",
      "code_information": [
        {
          "code": "3602685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1086,
          "minimum": 371.2652,
          "maximum": 788.1102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 551.6771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-10-8 MREYE",
      "code_information": [
        {
          "code": "3602686",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-8 MREYE G42423",
      "code_information": [
        {
          "code": "3602687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION MREYE G42414",
      "code_information": [
        {
          "code": "3602690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-5 MREYE G42410",
      "code_information": [
        {
          "code": "3602691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-4 MREYE G42409",
      "code_information": [
        {
          "code": "3602692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-3 MREYE G42408",
      "code_information": [
        {
          "code": "3602693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 663.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-2-3 MREYE G42406",
      "code_information": [
        {
          "code": "3602694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 914,
          "minimum": 312.4645,
          "maximum": 7516.2476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.3029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 15MM X 15G",
      "code_information": [
        {
          "code": "3602699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1426,
          "minimum": 487.4993,
          "maximum": 1034.8482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 724.3937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CO 2.10MM NS1806.002 STE",
      "code_information": [
        {
          "code": "3602710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1658,
          "minimum": 566.8119,
          "maximum": 5094.4321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 842.2474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2883-01-024",
      "code_information": [
        {
          "code": "3602763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1645,
          "minimum": 265.2597,
          "maximum": 1193.7765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 835.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC SAW 1.27MM 71440375",
      "code_information": [
        {
          "code": "3602770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 5079.4174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 375.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X340MM 1806-4260S",
      "code_information": [
        {
          "code": "3602772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1134,
          "minimum": 387.6748,
          "maximum": 1969.7062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 576.0607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 13X300MM 351.27",
      "code_information": [
        {
          "code": "3602773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3542,
          "minimum": 1210.8853,
          "maximum": 2570.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1799.3006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 360.05S",
      "code_information": [
        {
          "code": "3602774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4064,
          "minimum": 522.734,
          "maximum": 2949.2448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2064.4714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 38FR 68138",
      "code_information": [
        {
          "code": "3602784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 462,
          "minimum": 157.9416,
          "maximum": 42159.6093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 234.6914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/15CM CA1815",
      "code_information": [
        {
          "code": "3602790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 11543.5238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 30FR 68130",
      "code_information": [
        {
          "code": "3602796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 418.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 292.6022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 32FR 68132",
      "code_information": [
        {
          "code": "3602797",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 602,
          "minimum": 205.8026,
          "maximum": 436.8714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.81,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 36FR 68136",
      "code_information": [
        {
          "code": "3602798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 576,
          "minimum": 196.9142,
          "maximum": 418.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 292.6022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 34FR 68134",
      "code_information": [
        {
          "code": "3602799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR",
      "code_information": [
        {
          "code": "3602805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 436,
          "minimum": 149.0531,
          "maximum": 368.6943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 221.4836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94895",
      "code_information": [
        {
          "code": "3602818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 755.4537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 528.8176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94835",
      "code_information": [
        {
          "code": "3602819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1041,
          "minimum": 355.8813,
          "maximum": 755.4537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 528.8176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3602851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 207.4253,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 648.7032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 16G/15CM CA1615",
      "code_information": [
        {
          "code": "3602858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 14G/11CM CA1411",
      "code_information": [
        {
          "code": "3602859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 553.8756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 X523H",
      "code_information": [
        {
          "code": "3602867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0  X513H",
      "code_information": [
        {
          "code": "3602868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.0353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7 W/QC STD TP 71933035",
      "code_information": [
        {
          "code": "3602893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 1656.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1159.2332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-W/ NEEDLES #0 SUTURE",
      "code_information": [
        {
          "code": "3602933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3020,
          "minimum": 870.8526,
          "maximum": 2191.614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1534.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-EXTREMITIES UNIVERSAL",
      "code_information": [
        {
          "code": "3602935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1194",
      "code_information": [
        {
          "code": "3602936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 328.5321,
          "maximum": 4768.0014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 488.1784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ201",
      "code_information": [
        {
          "code": "3602938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1157.2126,
          "maximum": 2456.4945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1719.5461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ101",
      "code_information": [
        {
          "code": "3602939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3385,
          "minimum": 1157.2126,
          "maximum": 2509.6793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1719.5461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 180MM P45-112-0180",
      "code_information": [
        {
          "code": "3602943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6756,
          "minimum": 2249.4245,
          "maximum": 4902.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3431.9804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 180MM P45-180-0180",
      "code_information": [
        {
          "code": "3602944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4045,
          "minimum": 1382.8434,
          "maximum": 2935.4565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2054.8195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-4H THRED P45-921-0004",
      "code_information": [
        {
          "code": "3602945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2618,
          "minimum": 870.8526,
          "maximum": 1899.8826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1329.9178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CALIBRA 4X165MM 0225-000",
      "code_information": [
        {
          "code": "3602953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2376,
          "minimum": 812.2709,
          "maximum": 1922.9938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1206.9842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5MMPINX9.5MMROD 1151-200",
      "code_information": [
        {
          "code": "3602954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3458,
          "minimum": 1182.1687,
          "maximum": 2509.4706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1756.6294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-9.5 X 9.5MM ROD 1151-200",
      "code_information": [
        {
          "code": "3602955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3458,
          "minimum": 1182.1687,
          "maximum": 2509.4706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1756.6294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X150MM 1152-150",
      "code_information": [
        {
          "code": "3602956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X200MM 1152-200",
      "code_information": [
        {
          "code": "3602957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X250MM 1152-250",
      "code_information": [
        {
          "code": "3602958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X300 1152-300",
      "code_information": [
        {
          "code": "3602959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 789.366,
          "maximum": 3591.2938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN ASSEM 1158-000",
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        {
          "code": "3602960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6458,
          "minimum": 1377.4597,
          "maximum": 4686.5706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3280.5994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VENASEAL CLOSURE VS-404",
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        {
          "code": "3602966",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4936,
          "minimum": 1687.4449,
          "maximum": 3582.0552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2507.4386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-5.5 P20-910-5500",
      "code_information": [
        {
          "code": "3602974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 1250.3811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 875.2668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK -.5 P20-915-5500",
      "code_information": [
        {
          "code": "3602976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 4037.8421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 875.2668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PROTECT 5.0 P45-198-5000",
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        {
          "code": "3602978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5320",
      "code_information": [
        {
          "code": "3603015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1167,
          "minimum": 398.9563,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 592.8243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-150MM THRED P45-310-0150",
      "code_information": [
        {
          "code": "3603022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 1522.6018,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 345.9412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-CUBE 4H P45-925-0004",
      "code_information": [
        {
          "code": "3603023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2738,
          "minimum": 870.8526,
          "maximum": 1986.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1390.8766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-3/16\\\" SQ P99-000-316P",
      "code_information": [
        {
          "code": "3603028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 199.0838,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 8MM P45-914-0003",
      "code_information": [
        {
          "code": "3603029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 9787.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.8604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ULTRALOOP-HS FIBER 72205445",
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        {
          "code": "3603051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 437.8874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM PROBE 9700-020-100",
      "code_information": [
        {
          "code": "3603057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21773,
          "minimum": 1205.6248,
          "maximum": 15800.6661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11060.4663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/F P01-900-1702",
      "code_information": [
        {
          "code": "3603060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 358.6845,
          "maximum": 1963.0185,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1374.1129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F40 64611",
      "code_information": [
        {
          "code": "3603068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 50.291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63306",
      "code_information": [
        {
          "code": "3603069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 98.5501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63305",
      "code_information": [
        {
          "code": "3603070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 66.3218,
          "maximum": 149.0348,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 98.5501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE SMALL",
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        {
          "code": "3603071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE LARGE",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 136.1413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE MEDIUM",
      "code_information": [
        {
          "code": "3603073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 45.6002,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.1413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYNG SZ4 321400000U",
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        {
          "code": "3603074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 28.0329,
          "maximum": 165.7178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.6552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL WIDE",
      "code_information": [
        {
          "code": "3603075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 101.8757,
          "maximum": 216.2586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL FITPACK",
      "code_information": [
        {
          "code": "3603076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 140.7858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 98.5501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X400MM 1152-400",
      "code_information": [
        {
          "code": "3603081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 60.0588,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1172.9489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP427H",
      "code_information": [
        {
          "code": "3603082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 2619.7871,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOULTION-WOUND VASHE 118ML",
      "code_information": [
        {
          "code": "3603095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 225,
          "minimum": 76.9196,
          "maximum": 176.8398,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ULTRABRAID SZ2 7210915",
      "code_information": [
        {
          "code": "3603096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 35594.2927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 161.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-50 COBLATION 72290037",
      "code_information": [
        {
          "code": "3603101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1887,
          "minimum": 287.5037,
          "maximum": 1369.3959,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 958.5771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3603102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 517,
          "minimum": 176.7441,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.6308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-5.5 72202530",
      "code_information": [
        {
          "code": "3603103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-HRVST SYS SK27",
      "code_information": [
        {
          "code": "3603104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5613,
          "minimum": 1474.2211,
          "maximum": 4073.3541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2851.3479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INST-GUIDE RELEASE SN20",
      "code_information": [
        {
          "code": "3603105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 8186.3481,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1346.6815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-HK BONE REMOVAL SN25",
      "code_information": [
        {
          "code": "3603107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1346.6815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRIPLE EDGE INST SN21",
      "code_information": [
        {
          "code": "3603108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 110.6639,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1346.6815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0 C013D",
      "code_information": [
        {
          "code": "3603114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 163,
          "minimum": 55.724,
          "maximum": 797.4474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.8024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-FILSHIE AVM-851J",
      "code_information": [
        {
          "code": "3603115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1434,
          "minimum": 490.2342,
          "maximum": 8660.1453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 728.4577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERC SUTURE AR-7267",
      "code_information": [
        {
          "code": "3603119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 3939.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1687.5428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 14MM 2022-30-014S",
      "code_information": [
        {
          "code": "3603135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 1159.6686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 811.768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 16MM 2022-30-016S",
      "code_information": [
        {
          "code": "3603136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1598,
          "minimum": 546.3,
          "maximum": 1159.6686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 811.768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PIN PROT WHT 5027-1-040",
      "code_information": [
        {
          "code": "3603139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-DELIVERY STRBL-14F-075",
      "code_information": [
        {
          "code": "3603178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3603179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2435.812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3603180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2435.812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 8F",
      "code_information": [
        {
          "code": "3603181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 1639.242,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2435.812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 9F",
      "code_information": [
        {
          "code": "3603182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4795,
          "minimum": 51.7173,
          "maximum": 3479.7315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2435.812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 8MM 022108-10",
      "code_information": [
        {
          "code": "3603183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 712.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TPR 3MM 5407-FA3-030",
      "code_information": [
        {
          "code": "3603184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1282,
          "minimum": 438.2708,
          "maximum": 930.3474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 651.2432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 6MM 5820-010-160",
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        {
          "code": "3603185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1494,
          "minimum": 510.7461,
          "maximum": 1084.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 758.9371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RASP-HELI 3.2MM 5120-080-030",
      "code_information": [
        {
          "code": "3603186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1446,
          "minimum": 494.3366,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 734.5535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 7205306",
      "code_information": [
        {
          "code": "3603188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 501.6022,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 231.1354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 1683H",
      "code_information": [
        {
          "code": "3603192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 4507.1905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.5913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3603196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3050,
          "minimum": 178.5081,
          "maximum": 2213.385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1549.3695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT C0R47",
      "code_information": [
        {
          "code": "3603197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.0648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS CFF74",
      "code_information": [
        {
          "code": "3603198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 60.0588,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEEDLE WINGED INF WNIS01",
      "code_information": [
        {
          "code": "3603199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 914.2284,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED CTF73",
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        {
          "code": "3603214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANN-VENOUS HI FLO 24FR 69324",
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        {
          "code": "3603215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 141.1902,
          "maximum": 4958.7437,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A404",
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        {
          "code": "3603218",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 134.3529,
          "maximum": 364.8016,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR 72201513",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 656,
          "minimum": 224.2633,
          "maximum": 476.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 615,
          "minimum": 210.2469,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SOMFIT 7037-1001-00",
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        {
          "code": "3603227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 171.6162,
          "maximum": 1705.5587,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MOD 12MM 2022-30-012S",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 546.3,
          "maximum": 1334.64,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
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        {
          "code": "3603277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 81.7057,
          "maximum": 35676.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-ZINC OXIDE REMDEY 4OZ",
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        {
          "code": "3603279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 25.6399,
          "maximum": 1897.4132,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT X 2.4/45° 378824",
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        {
          "code": "3603290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 101.2102,
          "maximum": 223.5156,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-STR SP 15° 378235",
      "code_information": [
        {
          "code": "3603291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 4507.1905,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 92.4542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM BP 0808-115-800",
      "code_information": [
        {
          "code": "3603299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10281,
          "minimum": 1346.3181,
          "maximum": 7460.9217,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 5222.6452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-11G VP 0605-411-000",
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        {
          "code": "3603300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2421,
          "minimum": 827.6548,
          "maximum": 1756.9197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1229.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-10G VP 0605-410-000",
      "code_information": [
        {
          "code": "3603301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2421,
          "minimum": 497.7095,
          "maximum": 1756.9197,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1229.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BL 3X600 AR-9091BK-30S",
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        {
          "code": "3603303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL 4.2MM AR-9091-42",
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        {
          "code": "3603304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 26349.6863,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CM VP 11G 0306-511-000",
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        {
          "code": "3603319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 206.4864,
          "maximum": 2716.5485,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5 REAMING 6143.2571",
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        {
          "code": "3603340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1032.4319,
          "maximum": 5862.9623,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM F/ANCHOR 72203785",
      "code_information": [
        {
          "code": "3603349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 514.8485,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X5MM 60-16005",
      "code_information": [
        {
          "code": "3603351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 438.9545,
          "maximum": 931.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X26MM 60-16526",
      "code_information": [
        {
          "code": "3603355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 492.9691,
          "maximum": 1046.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X35 92-16135",
      "code_information": [
        {
          "code": "3603356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 480.4704,
          "maximum": 1351.9791,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X50/5M 60-15105",
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        {
          "code": "3603363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 508.6949,
          "maximum": 1511.4798,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 755.8891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X110/20M 60-15620",
      "code_information": [
        {
          "code": "3603364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 726.2666,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1380.7168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13X50/13G NN-2003",
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        {
          "code": "3603396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 7026.8796,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 10888.7656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL DIST 2.8MM 4040-000",
      "code_information": [
        {
          "code": "3603404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1975,
          "minimum": 675.1831,
          "maximum": 6311.1789,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1003.2802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 1.5X230MM 0109-230",
      "code_information": [
        {
          "code": "3603406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1146,
          "minimum": 391.7771,
          "maximum": 1380.7963,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE HAND 415S002350",
      "code_information": [
        {
          "code": "3603407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 848.8504,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1261.3392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CIRCUIT NEONATE DUAL LIMB",
      "code_information": [
        {
          "code": "3603429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 754,
          "minimum": 257.7661,
          "maximum": 547.1778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 383.0245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SUCTION TABLE 8Q70R",
      "code_information": [
        {
          "code": "3603430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 633,
          "minimum": 216.4005,
          "maximum": 909.7796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 321.5577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5X150 CN P41-910-5015",
      "code_information": [
        {
          "code": "3603431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 831.0716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AO CONN P65-001-0001-SK",
      "code_information": [
        {
          "code": "3603438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 6996.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-QUAD TIP 2762-01-0003",
      "code_information": [
        {
          "code": "3603444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3155,
          "minimum": 1078.5836,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1602.7084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2.5CM M00510880",
      "code_information": [
        {
          "code": "3603498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 1242.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 869.6789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2CM M00510870",
      "code_information": [
        {
          "code": "3603499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1712,
          "minimum": 585.2726,
          "maximum": 3296.0047,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 869.6789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GENERATOR-RF PROC RLVRFGPR",
      "code_information": [
        {
          "code": "3603504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 631.0825,
          "maximum": 14704.3962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 937.7495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ADD ACCESS INST RLV0075",
      "code_information": [
        {
          "code": "3603508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 11091.9706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2006.0525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ACCESS INSTRUMENT RLV0045",
      "code_information": [
        {
          "code": "3603510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 9838,
          "minimum": 3363.2665,
          "maximum": 7139.4366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4997.6056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DAVINCI INSUFF TUBE 470551",
      "code_information": [
        {
          "code": "3603512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1264,
          "minimum": 432.1172,
          "maximum": 3249.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.0994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/10CM NN-8006",
      "code_information": [
        {
          "code": "3603527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 16702,
          "minimum": 1866.2716,
          "maximum": 12120.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 8484.449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X60/13G NN-2004",
      "code_information": [
        {
          "code": "3603530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 632.2857,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10888.7656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 40X11 SM-4011M",
      "code_information": [
        {
          "code": "3603538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 3296.0047,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ALLOGRAFT-22.5MM ABS-4057D-225",
      "code_information": [
        {
          "code": "3603542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5686,
          "minimum": 1943.8436,
          "maximum": 4126.3302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2888.4311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL-1.5x48MM 03.130.212",
      "code_information": [
        {
          "code": "3603544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 124.0103,
          "maximum": 751.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 525.7696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP76",
      "code_information": [
        {
          "code": "3603545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 113.2818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE 9X102 HTOE 05-306",
      "code_information": [
        {
          "code": "3603547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 394,
          "minimum": 134.6948,
          "maximum": 285.9258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 200.1481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.35X150 AR-8943-01S",
      "code_information": [
        {
          "code": "3603548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLECTOR-SPECIMEN NN-9002",
      "code_information": [
        {
          "code": "3603569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 700,
          "minimum": 239.3054,
          "maximum": 793.5547,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 355.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/13CM NN-8007",
      "code_information": [
        {
          "code": "3603587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 18660,
          "minimum": 6379.1983,
          "maximum": 13541.562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 9479.0934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X95/13G NN-2006",
      "code_information": [
        {
          "code": "3603588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 7327.8733,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10888.7656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X75/13G NN-2005",
      "code_information": [
        {
          "code": "3603589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21435,
          "minimum": 62.8393,
          "maximum": 15555.3795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10888.7656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-MYRID NICO NN-9001",
      "code_information": [
        {
          "code": "3603590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 551.6512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 7FRX65C",
      "code_information": [
        {
          "code": "3603592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1624,
          "minimum": 555.1885,
          "maximum": 1178.5368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 824.9758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 5FRX50C",
      "code_information": [
        {
          "code": "3603593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1624,
          "minimum": 555.1885,
          "maximum": 1178.5368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 824.9758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 9FRX65C",
      "code_information": [
        {
          "code": "3603594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1882,
          "minimum": 643.3897,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 956.0372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-20-22FR/45CM G52835",
      "code_information": [
        {
          "code": "3603768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1759,
          "minimum": 601.3403,
          "maximum": 1276.5063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 893.5544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16-18FR/45CM G52834",
      "code_information": [
        {
          "code": "3603769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1759,
          "minimum": 601.3403,
          "maximum": 2381.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 893.5544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-32-35MM 102024003",
      "code_information": [
        {
          "code": "3603771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 906.2837,
          "maximum": 2465.7474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1346.6815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.4X27 ST 60-14126",
      "code_information": [
        {
          "code": "3603794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 3325.478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 564.8849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOWN-WARMING BEAR PAW 81001",
      "code_information": [
        {
          "code": "3603809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 6791.0932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.8823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPYSCOPE DS II M00546610",
      "code_information": [
        {
          "code": "3603810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12212,
          "minimum": 1866.2716,
          "maximum": 8862.2484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6203.5739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-EHL 1.9F 375CM M00546620",
      "code_information": [
        {
          "code": "3603814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2879,
          "minimum": 984.2289,
          "maximum": 2089.2903,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1462.5032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONEMILL MD 5420-MED-000",
      "code_information": [
        {
          "code": "3603815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3354,
          "minimum": 1146.6147,
          "maximum": 5094.4321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1703.7985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CRV DIAMOND 15° 1600650",
      "code_information": [
        {
          "code": "3603818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CYLINDER 60° 1600578",
      "code_information": [
        {
          "code": "3603819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X200MM P99-192-1620",
      "code_information": [
        {
          "code": "3603836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 6.6732,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 509.514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2.0 3846T",
      "code_information": [
        {
          "code": "3603837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 8.7084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6.0959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 7-0 Z135H",
      "code_information": [
        {
          "code": "3603876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 273,
          "minimum": 93.3291,
          "maximum": 9887.458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.6813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 45X6 SM-4506",
      "code_information": [
        {
          "code": "3603888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 8750.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-38MM ARS743201",
      "code_information": [
        {
          "code": "3603895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 798.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-14X127MM ARS743303",
      "code_information": [
        {
          "code": "3603897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 1140.0747,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 798.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE .9MM 57S90005",
      "code_information": [
        {
          "code": "3603901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 468.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 327.6535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM MXM-072-19",
      "code_information": [
        {
          "code": "3603904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 615.0149,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 913.874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-76/3 ARS743202",
      "code_information": [
        {
          "code": "3603910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1571,
          "minimum": 537.0697,
          "maximum": 4140.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 798.0523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 8.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.0295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603923",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.0295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.0295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 6.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 49.4929,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.0295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SM CHLD NR34015813",
      "code_information": [
        {
          "code": "3603926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015814",
      "code_information": [
        {
          "code": "3603927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 64.5873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.2111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PRO-FLOW NR37000145",
      "code_information": [
        {
          "code": "3603928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMETRY EM951160CP",
      "code_information": [
        {
          "code": "3603931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 41.7075,
          "maximum": 148.0428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.63,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ADULT NR34015818",
      "code_information": [
        {
          "code": "3603932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 54.4275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.0992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASALNR354S5011",
      "code_information": [
        {
          "code": "3603933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 45.6002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015816",
      "code_information": [
        {
          "code": "3603934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 72.8491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.6552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG WEBB NR104B1420",
      "code_information": [
        {
          "code": "3603935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 131,
          "minimum": 44.7843,
          "maximum": 294.1769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.5467,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-EEG 8OZ NR10200005",
      "code_information": [
        {
          "code": "3603936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 529,
          "minimum": 87.8638,
          "maximum": 383.8953,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 268.7267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUPREP-4OZ TUBE NR10210004",
      "code_information": [
        {
          "code": "3603937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 158,
          "minimum": 32.8099,
          "maximum": 114.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.2624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THERMOCAN NR34015808",
      "code_information": [
        {
          "code": "3603938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 59,
          "minimum": 20.17,
          "maximum": 17894.7419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR/6.7MM 80220",
      "code_information": [
        {
          "code": "3603955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 196.5921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CLEARVUE LARYNG #3",
      "code_information": [
        {
          "code": "3603957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NOMOLINE LH NASAL/ORAL",
      "code_information": [
        {
          "code": "3603958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 208,
          "minimum": 71.1079,
          "maximum": 150.9456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.6619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 22FR BE2050",
      "code_information": [
        {
          "code": "3603960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 864.3087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 605.0161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LITHOTRIPER PROBE 3.9MM",
      "code_information": [
        {
          "code": "3603972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4400,
          "minimum": 1504.2054,
          "maximum": 3193.08,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2235.156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T-15 TORQUE 702750",
      "code_information": [
        {
          "code": "3603979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3611,
          "minimum": 1234.474,
          "maximum": 5646.6394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1834.3519,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIMITER-TORQUE 2.5NM 702760",
      "code_information": [
        {
          "code": "3603985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4015,
          "minimum": 1372.5874,
          "maximum": 4387.0729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2039.5798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/15 STPL THN00482",
      "code_information": [
        {
          "code": "3603988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2099,
          "minimum": 717.5743,
          "maximum": 1523.2443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1066.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/20 STPL THN00483",
      "code_information": [
        {
          "code": "3603989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2099,
          "minimum": 717.5743,
          "maximum": 1523.2443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1066.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA 22.5FR 7275",
      "code_information": [
        {
          "code": "3604022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 3450.6005,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM*CLEARIFY 21-345",
      "code_information": [
        {
          "code": "3604025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 194.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 CHROMIC GUT 792G",
      "code_information": [
        {
          "code": "3604027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 250,
          "minimum": 85.4662,
          "maximum": 8732.9944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 126.9975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-NANO 29.5X7MM SM-3115",
      "code_information": [
        {
          "code": "3604043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 637.2906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-MET 20MM MPN20120",
      "code_information": [
        {
          "code": "3604048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 1135.6751,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1687.5428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHAL 20MM MPN20020",
      "code_information": [
        {
          "code": "3604049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 667.8761,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1687.5428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM SHT MSTD1030",
      "code_information": [
        {
          "code": "3604050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE DUAL 844023S",
      "code_information": [
        {
          "code": "3604137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 291,
          "minimum": 71.1808,
          "maximum": 211.1787,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 147.8251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 2X200 MSG20200",
      "code_information": [
        {
          "code": "3604156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 1511.4798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 363.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.6 F/5.5MM MSN10013",
      "code_information": [
        {
          "code": "3604157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2718,
          "minimum": 667.8761,
          "maximum": 1972.4526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1380.7168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM LNG MSTD0030",
      "code_information": [
        {
          "code": "3604158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 2274.449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA-G GENERATION 2",
      "code_information": [
        {
          "code": "3604162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10740,
          "minimum": 3671.6286,
          "maximum": 7794.018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5455.8126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-STAPLE SZ THN00292",
      "code_information": [
        {
          "code": "3604165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2014,
          "minimum": 688.5158,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1023.0919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 5.0MM 3100-01-0005",
      "code_information": [
        {
          "code": "3604167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 795.7791,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1705.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 2.4MM 2900-04-0229",
      "code_information": [
        {
          "code": "3604168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1431,
          "minimum": 489.2086,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 726.9337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-6.5MM 3100-01-0007",
      "code_information": [
        {
          "code": "3604169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 1147.6403,
          "maximum": 8783.5995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1705.3224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-7X90 3200-01-7090",
      "code_information": [
        {
          "code": "3604170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 15795,
          "minimum": 5399.7555,
          "maximum": 11462.4315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 8023.702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SONATA DE-001-10",
      "code_information": [
        {
          "code": "3604172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 877,
          "minimum": 278.05,
          "maximum": 636.4389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 445.5072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS BONE BX 0306-115-000",
      "code_information": [
        {
          "code": "3604196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 798,
          "minimum": 272.8082,
          "maximum": 4376.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 405.376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-DSG XS 2.5MM P1-AU514",
      "code_information": [
        {
          "code": "3604197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 7870,
          "minimum": 551.6512,
          "maximum": 5711.259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3997.8813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DISTRACTOR 12MM 02.600.022",
      "code_information": [
        {
          "code": "3604198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 992,
          "minimum": 339.1299,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 503.9261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-#0/8\\\"\\\" GREEN VLOCA008L",
      "code_information": [
        {
          "code": "3604209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1317,
          "minimum": 450.236,
          "maximum": 955.7469,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 669.0228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX977",
      "code_information": [
        {
          "code": "3604217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 507.7193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.5568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ACESSA 7300",
      "code_information": [
        {
          "code": "3604227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14892,
          "minimum": 265.8158,
          "maximum": 10807.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7564.9871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-HEAD SILVERMAN SZ F",
      "code_information": [
        {
          "code": "3604228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.8192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X12MM AR-300-B003",
      "code_information": [
        {
          "code": "3604244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 1790.3019,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1253.2113,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUT 2 P41-960-0020",
      "code_information": [
        {
          "code": "3604263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1723,
          "minimum": 589.0332,
          "maximum": 1250.3811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 875.2668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5.5X150 CN P41-910-5515",
      "code_information": [
        {
          "code": "3604264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1187.2452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 831.0716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X150 CN P41-910-4015",
      "code_information": [
        {
          "code": "3604265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1187.2452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 831.0716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-GPS LONG 6143.2515",
      "code_information": [
        {
          "code": "3604278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6702,
          "minimum": 836.3744,
          "maximum": 4863.6414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3404.549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 8.0",
      "code_information": [
        {
          "code": "3604284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 7.5",
      "code_information": [
        {
          "code": "3604285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED",
      "code_information": [
        {
          "code": "3604286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER TRACH PORTEX 100",
      "code_information": [
        {
          "code": "3604287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 51.7173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEMALE TO FEMALE",
      "code_information": [
        {
          "code": "3604289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 1322.9619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-1.8MM PERK AR-3610PK-3",
      "code_information": [
        {
          "code": "3604294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1586,
          "minimum": 542.1977,
          "maximum": 1763.3931,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 805.6721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SR8 GEMINI AR-6572",
      "code_information": [
        {
          "code": "3604301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 3149.1943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 203.704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLSRE SKN 22CM EF70401",
      "code_information": [
        {
          "code": "3604305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 711,
          "minimum": 243.0659,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 361.1809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH 14 1/4\\\" 020116801",
      "code_information": [
        {
          "code": "3604307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 8850.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 662.9269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-TISSUE HIGH EX71010",
      "code_information": [
        {
          "code": "3604311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-WIRE FIX XL 76-10104",
      "code_information": [
        {
          "code": "3604319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1375,
          "minimum": 470.0642,
          "maximum": 997.8375,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 698.4862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR PEDIATRIC S-1003",
      "code_information": [
        {
          "code": "3604329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 264,
          "minimum": 90.2523,
          "maximum": 5757.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 134.1094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT SHORT 71-6130S",
      "code_information": [
        {
          "code": "3604330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10354,
          "minimum": 870.8526,
          "maximum": 7513.8978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5259.7285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 4H 76-10140",
      "code_information": [
        {
          "code": "3604333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 859.5191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 2H 76-10125",
      "code_information": [
        {
          "code": "3604334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1692,
          "minimum": 578.4353,
          "maximum": 1227.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 859.5191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 200MM 76-11200",
      "code_information": [
        {
          "code": "3604335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1151,
          "minimum": 207.4253,
          "maximum": 835.2807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 584.6965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 115MM 76-11115",
      "code_information": [
        {
          "code": "3604337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 934,
          "minimum": 319.3018,
          "maximum": 3255.4094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 474.4627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FH 4.2MM AR-9091F-42",
      "code_information": [
        {
          "code": "3604351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1449.2955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CON 4.3X13MM AR-300-B101",
      "code_information": [
        {
          "code": "3604352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2470,
          "minimum": 7.7854,
          "maximum": 1792.479,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1254.7353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE SKIN EF70466",
      "code_information": [
        {
          "code": "3604355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 933,
          "minimum": 101.7663,
          "maximum": 677.0781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 473.9547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEN-ADHESIVE EP70412",
      "code_information": [
        {
          "code": "3604356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.9622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACTIVALVE-PROVOX STRONG 7161",
      "code_information": [
        {
          "code": "3604357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 662.3151,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2006.0525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET ACCESS INST LV3 RLV0055",
      "code_information": [
        {
          "code": "3604369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12997,
          "minimum": 3490.6397,
          "maximum": 9431.9229,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6602.346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.6X200 AR-5050K-1",
      "code_information": [
        {
          "code": "3604376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.8192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM RC P01-DWL-0915",
      "code_information": [
        {
          "code": "3604386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-FOGARTY DSOFT33",
      "code_information": [
        {
          "code": "3604398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 2807.7489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.3844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-DRAIN/FLUSH LL AFA-LL",
      "code_information": [
        {
          "code": "3604403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 113.7898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #4",
      "code_information": [
        {
          "code": "3604406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 294.6342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 206.2439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-6 THD/10 HEX 76-10180",
      "code_information": [
        {
          "code": "3604415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 235,
          "minimum": 80.3382,
          "maximum": 175.1715,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 119.3776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-FLANGE 10HX 76-10182",
      "code_information": [
        {
          "code": "3604416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 3503.9861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.0168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD +3OS/25MM MWJ007",
      "code_information": [
        {
          "code": "3604423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5858,
          "minimum": 580.5684,
          "maximum": 4251.1506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2975.8054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODEL-REV BONE MWJ015",
      "code_information": [
        {
          "code": "3604424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 14259.5162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.0 A-3938",
      "code_information": [
        {
          "code": "3604432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2061,
          "minimum": 506.051,
          "maximum": 1495.6677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1046.9674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 16FR 26-016",
      "code_information": [
        {
          "code": "3604433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 660.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 462.2709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 12FR 26-012",
      "code_information": [
        {
          "code": "3604434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 660.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 462.2709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 18FR 26-018",
      "code_information": [
        {
          "code": "3604435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 910,
          "minimum": 311.097,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 462.2709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-6X150 CN P41-910-6015",
      "code_information": [
        {
          "code": "3604457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1636,
          "minimum": 559.2909,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 831.0716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CAL 5.5MM S0288-200",
      "code_information": [
        {
          "code": "3604470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2470,
          "minimum": 844.4062,
          "maximum": 3563.4888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1254.7353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.6MM TRC AR-18700-71",
      "code_information": [
        {
          "code": "3604479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 638.9589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO",
      "code_information": [
        {
          "code": "3604489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 686,
          "minimum": 71.1808,
          "maximum": 497.8302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 348.4811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1069210",
      "code_information": [
        {
          "code": "3604490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 4015.5981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-HO 7/1.6X80 P99-205-1608",
      "code_information": [
        {
          "code": "3604512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1065,
          "minimum": 364.0861,
          "maximum": 877.5258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 541.0093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GRAFT SIZING AR-1676ST",
      "code_information": [
        {
          "code": "3604518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2079,
          "minimum": 710.737,
          "maximum": 8964.332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1056.1112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMANN .157X9\\\"\\\" KI71615",
      "code_information": [
        {
          "code": "3604550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 1705.0026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL SP-78105",
      "code_information": [
        {
          "code": "3604567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1274,
          "minimum": 435.5358,
          "maximum": 924.5418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 647.1793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 1MM 5820-013-010",
      "code_information": [
        {
          "code": "3604568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 427.6409,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 648.7032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 12X18/2 DS24",
      "code_information": [
        {
          "code": "3604569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 769,
          "minimum": 262.8941,
          "maximum": 558.0633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 390.6443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/0 DS26",
      "code_information": [
        {
          "code": "3604570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 832,
          "minimum": 284.4316,
          "maximum": 603.7824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 422.6477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 29/37 TF2937O",
      "code_information": [
        {
          "code": "3604581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 309.8739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-AMPLATZ 8F M0062601010",
      "code_information": [
        {
          "code": "3604584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 481,
          "minimum": 164.437,
          "maximum": 349.0617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.3432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEM 19F/6.3 96570-119",
      "code_information": [
        {
          "code": "3604596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2245,
          "minimum": 767.4866,
          "maximum": 1629.1965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1140.4375,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 19F/6.3MM 96530-119",
      "code_information": [
        {
          "code": "3604597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 848.8504,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1261.3392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 21F/7MM 96530-121",
      "code_information": [
        {
          "code": "3604598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2483,
          "minimum": 134.0201,
          "maximum": 1801.9131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1261.3392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WHITE 15X12MM DLP-W11",
      "code_information": [
        {
          "code": "3604599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 174.8937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-YELLOW 15X12MM DLP-S11",
      "code_information": [
        {
          "code": "3604600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-11MM 261222",
      "code_information": [
        {
          "code": "3604605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 1943.4246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1360.3972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 650-750CC SZHP68650",
      "code_information": [
        {
          "code": "3604611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 550-640CC SZHP68550",
      "code_information": [
        {
          "code": "3604612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 425-455CC SZHP68425",
      "code_information": [
        {
          "code": "3604613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.4357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 320-340CC SZHP68320",
      "code_information": [
        {
          "code": "3604614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 549,
          "minimum": 187.6838,
          "maximum": 398.4093,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 278.8865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 200-260CC SZHP68200",
      "code_information": [
        {
          "code": "3604615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 750-800CC SZHP68750",
      "code_information": [
        {
          "code": "3604616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 577.6572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 404.36,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 2MM 5820-010-120",
      "code_information": [
        {
          "code": "3604621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 3MM 5820-010-130",
      "code_information": [
        {
          "code": "3604622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 4MM 5820-010-140",
      "code_information": [
        {
          "code": "3604623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 3MM 5820-012-030",
      "code_information": [
        {
          "code": "3604624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 436.5614,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 648.7032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 4MM 5820-012-040",
      "code_information": [
        {
          "code": "3604625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1494,
          "minimum": 510.7461,
          "maximum": 1084.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 758.9371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 3 5820-013-030",
      "code_information": [
        {
          "code": "3604626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 4 5820-013-040",
      "code_information": [
        {
          "code": "3604627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 693.4063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SAHARA S-1150-08LF",
      "code_information": [
        {
          "code": "3604628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1182,
          "minimum": 37.8148,
          "maximum": 857.7774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 600.4442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 20FR 123120",
      "code_information": [
        {
          "code": "3604629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12X150MM FE CFF71",
      "code_information": [
        {
          "code": "3604631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.0648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X150MM FE CFF01",
      "code_information": [
        {
          "code": "3604632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X100MM BLADE CFB03",
      "code_information": [
        {
          "code": "3604633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 47.2685,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 9MM 022109-10",
      "code_information": [
        {
          "code": "3604634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 61.6845,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 10MM 022110-10",
      "code_information": [
        {
          "code": "3604635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 12MM 022112-10",
      "code_information": [
        {
          "code": "3604636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 67.4901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 14MM 022114-10",
      "code_information": [
        {
          "code": "3604637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 70.3929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 16MM 022116-10",
      "code_information": [
        {
          "code": "3604638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGAMAX 5MM CLIP EL5ML",
      "code_information": [
        {
          "code": "3000771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1389,
          "minimum": 474.8503,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 705.5981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380EM",
      "code_information": [
        {
          "code": "3003259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3188,
          "minimum": 1089.8652,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1619.4721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-I-STAT CREATININE",
      "code_information": [
        {
          "code": "3004750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.1791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 22FR 30CC      266722",
      "code_information": [
        {
          "code": "3004837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.5273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.2473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CORONARY PERF    30055",
      "code_information": [
        {
          "code": "3010039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 118.6271,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.2725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE LITE 30-403LITE",
      "code_information": [
        {
          "code": "3010311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3419,
          "minimum": 1168.836,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1736.8178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN TWIST 2.7MM W/AO F",
      "code_information": [
        {
          "code": "3012109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2077,
          "minimum": 710.0533,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1055.0952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.0MM ASNIS",
      "code_information": [
        {
          "code": "3012113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1913,
          "minimum": 653.9875,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 971.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP NICU HNICU37",
      "code_information": [
        {
          "code": "3019903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z463G",
      "code_information": [
        {
          "code": "3032618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3058698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 919,
          "minimum": 314.1738,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 466.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPINPERC INS-5600",
      "code_information": [
        {
          "code": "3058755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2207,
          "minimum": 754.4957,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1121.1339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE 1.5X36",
      "code_information": [
        {
          "code": "3058775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.6796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 CX ALL",
      "code_information": [
        {
          "code": "3058846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2149.3057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PED 900PT531",
      "code_information": [
        {
          "code": "3059068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 722,
          "minimum": 246.8264,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.7688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-ABSOLUTE PSI-TEC",
      "code_information": [
        {
          "code": "3059124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 174.2406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LIGASURE SM  LF1212A",
      "code_information": [
        {
          "code": "3059951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1029.0132,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-LEVER EDGE    4100-01",
      "code_information": [
        {
          "code": "3059965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1454,
          "minimum": 497.0715,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST-OP XL MALE      1315",
      "code_information": [
        {
          "code": "3079661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 140,
          "minimum": 47.8611,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.1186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL HEALTHVENT 24HR 97021",
      "code_information": [
        {
          "code": "3081122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.6939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-GLOW AND TELL     1100-20",
      "code_information": [
        {
          "code": "3083225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 559,
          "minimum": 191.1025,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 283.9664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN CUFF 7.0MM",
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        {
          "code": "3085522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.4357,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM   70890830",
      "code_information": [
        {
          "code": "3526275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.6871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL EPISTAX 10CM",
      "code_information": [
        {
          "code": "3526349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 469,
          "minimum": 160.3346,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.2473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRING-MR EMPOWERCTA",
      "code_information": [
        {
          "code": "3526487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR GYN DYNJ60136",
      "code_information": [
        {
          "code": "3527022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 190.7606,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 283.4584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MOMOPTY 20X15 21201",
      "code_information": [
        {
          "code": "3549005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 156.5741,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 232.6594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-LAT VEIN WORLEY",
      "code_information": [
        {
          "code": "3549219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2264,
          "minimum": 773.982,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1150.0894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-PCL 2.4MMX10",
      "code_information": [
        {
          "code": "3549231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1371,
          "minimum": 468.6967,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Y-PORT-20 FR M00580641",
      "code_information": [
        {
          "code": "3549284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 65.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOAM-BUMP 10X6X6\\\" DYNJBUMP03",
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        {
          "code": "3549293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.7864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-0xx-000",
      "code_information": [
        {
          "code": "3549839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CEMENT MIX 0206-015-000",
      "code_information": [
        {
          "code": "3549999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 192.8118,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 286.5064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-INTERLOCKING 3MMX4CM M001",
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        {
          "code": "3550029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2529,
          "minimum": 864.5762,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1284.7067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-W/F L&L PED ALL 5002s",
      "code_information": [
        {
          "code": "3550092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.7191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-BRILL 3.5 682.108S",
      "code_information": [
        {
          "code": "3550131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 230.6275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP 180-210CC",
      "code_information": [
        {
          "code": "3550332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.3398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL",
      "code_information": [
        {
          "code": "3550461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 504.9421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STEM 2862-02-204",
      "code_information": [
        {
          "code": "3550481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2349,
          "minimum": 803.0406,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1193.2685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT LARGE YG-282T",
      "code_information": [
        {
          "code": "3550639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.0261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 0200-20",
      "code_information": [
        {
          "code": "3550659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1384,
          "minimum": 473.141,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 703.0582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-BONE 3.8X13CM AR-8380BC",
      "code_information": [
        {
          "code": "3550684",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 400.2961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110MM 213524",
      "code_information": [
        {
          "code": "3550809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 480.0505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CLEARCUT 5X13 AR-8500COS",
      "code_information": [
        {
          "code": "3550848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 788,
          "minimum": 269.3895,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 400.2961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND 2.5MM 1882569HS",
      "code_information": [
        {
          "code": "3559015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1938,
          "minimum": 662.5341,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 984.4846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LAMINARIA-#4 MED 60MM 021004",
      "code_information": [
        {
          "code": "3559244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 139,
          "minimum": 47.5192,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.6106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT OPEN EB240",
      "code_information": [
        {
          "code": "3559437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1159.2332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X56MM 03.130.202",
      "code_information": [
        {
          "code": "3559456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 525.7696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV",
      "code_information": [
        {
          "code": "3559628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 60.9588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWRIST 2.5MM 60-25326",
      "code_information": [
        {
          "code": "3559663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 564.8849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARDS-NEONATAL NOISE NON-MAG",
      "code_information": [
        {
          "code": "3598028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 215,
          "minimum": 73.5009,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 109.2178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-MULTIPURPOSE TUBING",
      "code_information": [
        {
          "code": "3598219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUB LIPO 3-TT-FILTRON",
      "code_information": [
        {
          "code": "3598384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2403,
          "minimum": 821.5013,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1220.7,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW 25CM NSLX125C",
      "code_information": [
        {
          "code": "3598495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2676,
          "minimum": 914.8304,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1359.3812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN",
      "code_information": [
        {
          "code": "3598509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1055,
          "minimum": 360.6674,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.9294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3598587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.6796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND HANZ RT LG",
      "code_information": [
        {
          "code": "3599041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 494,
          "minimum": 168.8812,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 250.9471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ATERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.5374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-SELF LOCKING 4933-0-802",
      "code_information": [
        {
          "code": "3600214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.5021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-6MM/SD PARA 108843106",
      "code_information": [
        {
          "code": "3600452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2006.0525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-EAR DISP 4015",
      "code_information": [
        {
          "code": "3600557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CADD PCA 108” 21-7391-24",
      "code_information": [
        {
          "code": "3600723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.3423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT FEEDINGTUBE G3561",
      "code_information": [
        {
          "code": "3600751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 394.2002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-LF",
      "code_information": [
        {
          "code": "3600788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1482.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 10' 251010J",
      "code_information": [
        {
          "code": "3600900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.0648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-SUCT&ANTICOAG BT275",
      "code_information": [
        {
          "code": "3601009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 196,
          "minimum": 67.0055,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS BIPOLAR 2MM",
      "code_information": [
        {
          "code": "3601053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1667,
          "minimum": 569.8887,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 846.8193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-100-4630",
      "code_information": [
        {
          "code": "3601111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2799,
          "minimum": 956.8797,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1421.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-HEAD 17.5 03.404.031S",
      "code_information": [
        {
          "code": "3601120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3893,
          "minimum": 1330.8799,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1977.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLUE STAPLE GCR40B",
      "code_information": [
        {
          "code": "3601345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1903,
          "minimum": 650.5688,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 966.705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47520",
      "code_information": [
        {
          "code": "3601391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 636.5115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 11X100MM 4922-8-100",
      "code_information": [
        {
          "code": "3601641",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1743,
          "minimum": 595.8705,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 885.4266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.0MM",
      "code_information": [
        {
          "code": "3601769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.7031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE",
      "code_information": [
        {
          "code": "3602129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 657.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 583.6805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 392.8027,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 583.6805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 25MM X 15G",
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        {
          "code": "3602700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1426,
          "minimum": 487.4993,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCRW-POST+NUT SET B0223000",
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        {
          "code": "3603037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2517,
          "minimum": 860.4739,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1278.6108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOWS-SOLO FITPACK SLP1SMSLA",
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        {
          "code": "3603077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 73.1506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREADED CTF03",
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        {
          "code": "3603177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGATION P65-001-0006-SK",
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        {
          "code": "3603437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1316,
          "minimum": 449.8942,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 668.5148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE SINGLE 800099S",
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        {
          "code": "3604138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 128,
          "minimum": 43.7587,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.0227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATE STD 20MM M0056183",
      "code_information": [
        {
          "code": "3604224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 101.5339,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 150.873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 3.1X20MM AR-300-B202",
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        {
          "code": "3604247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2467,
          "minimum": 843.3806,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM C P01-901-0901-S",
      "code_information": [
        {
          "code": "3604385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2705,
          "minimum": 924.7444,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1374.1129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET SCREW T7 5560010000",
      "code_information": [
        {
          "code": "3604395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 301.8667,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 448.5552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #3",
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        {
          "code": "3604407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 406,
          "minimum": 138.7971,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 206.2439,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-COAXIAL BIPSY 946x-VC-006",
      "code_information": [
        {
          "code": "1416380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 154.5958,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OPTIFIX-ABSORBABLE 0113126",
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        {
          "code": "3000012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 1095.517,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 7.3     310.495",
      "code_information": [
        {
          "code": "3002265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT LARYNGEAL 4MM",
      "code_information": [
        {
          "code": "3003289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 431.5336,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OXFORD SAW 506298",
      "code_information": [
        {
          "code": "3003294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 432.0897,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-TUR PK           786500",
      "code_information": [
        {
          "code": "3003816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 710.1397,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 96370-023",
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        {
          "code": "3004233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 988.1897,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-020",
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        {
          "code": "3008516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 11X280       357.404",
      "code_information": [
        {
          "code": "3012311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2482.4304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX     2274-25-500",
      "code_information": [
        {
          "code": "3012384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 612.8222,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 7.0X3.2",
      "code_information": [
        {
          "code": "3012900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 7.7854,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-HALO CUTTING HACF-0533",
      "code_information": [
        {
          "code": "3013285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EVICEL FIBRIN SEALANT 3905",
      "code_information": [
        {
          "code": "3021100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-SEALER 5MM     LF1637",
      "code_information": [
        {
          "code": "3021738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIPOLAR 675.170S",
      "code_information": [
        {
          "code": "3550116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 698.605S",
      "code_information": [
        {
          "code": "3550117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 17566.6429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER/SHAVER-ALL",
      "code_information": [
        {
          "code": "3550238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HAMMER-SLAP 694.008",
      "code_information": [
        {
          "code": "3550243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 7877.7126,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-DIRECT MEASURE 702495",
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        {
          "code": "3550617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 207.4253,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-HELIX 6.5 ADVANCE 222313",
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        {
          "code": "3550751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.7X160 A-8004.01",
      "code_information": [
        {
          "code": "3550825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 207.4253,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DRIVER 4 CANN A-8004.11",
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        {
          "code": "3550827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1146.6782,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-LIGASURE 37CM LF1944",
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        {
          "code": "3559070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 16MM XFR004216",
      "code_information": [
        {
          "code": "3559091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 6524.7213,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-WIRELESS CELL EX1151",
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        {
          "code": "3559233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-15MM/3.5OS 9159.3035",
      "code_information": [
        {
          "code": "3559597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 2.0",
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        {
          "code": "3559670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 134.5762,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3566817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 689.564,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40B GCS40B",
      "code_information": [
        {
          "code": "3598106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM 03.333.103",
      "code_information": [
        {
          "code": "3598147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 875.3014,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-STRT TIP BAYON 1590-01",
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          "code": "3598218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 108.9956,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH",
      "code_information": [
        {
          "code": "3598452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SUREFORM 60 480460",
      "code_information": [
        {
          "code": "3598611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 4517.2003,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 27CM APYX-27-TP",
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        {
          "code": "3598956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 491.0363,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-1X10.5MM BI 632.678S",
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        {
          "code": "3599051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERCLAGE AR-7268",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-CERCLAGE AR-7268T",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1128.883,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM 03.333.102",
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        {
          "code": "3599533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 716.2568,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-NANO 125MM AR-3210-0043",
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        {
          "code": "3600299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 667.8761,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-MINI COREDX M00515220",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 1147.2985,
          "maximum": 3531.235,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR CVD GCS40G",
      "code_information": [
        {
          "code": "3600838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2679.2898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-LARGE DV2012-LF",
      "code_information": [
        {
          "code": "3600953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-8-13MM P99-110-0813",
      "code_information": [
        {
          "code": "3601104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-UNIVERSAL PAD ARTICGEL",
      "code_information": [
        {
          "code": "3601634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 4183.5403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIBER OPTIC PTEYE-1",
      "code_information": [
        {
          "code": "3602127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 600.588,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2848.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE 45\\\" HAR745",
      "code_information": [
        {
          "code": "3602909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE HAR736",
      "code_information": [
        {
          "code": "3602910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 149.5909,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA 13CM PRE1101US",
      "code_information": [
        {
          "code": "3603187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 253.0255,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 11G NN-1000",
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        {
          "code": "3603528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 13G NN-1001",
      "code_information": [
        {
          "code": "3603586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 10376.826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY MAX M00546470",
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        {
          "code": "3603811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL M00546550",
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        {
          "code": "3603812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-RETRIEVAL M00546560",
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        {
          "code": "3603813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-8MM/CV SF30 488530",
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        {
          "code": "3603862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY 115CM G48240",
      "code_information": [
        {
          "code": "3603969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 1147.2985,
          "maximum": 3975.0028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 25 LS96555-025",
      "code_information": [
        {
          "code": "3604574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SUPERLOOP TUR 784415",
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        {
          "code": "3604601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3356,
          "minimum": 870.8526,
          "maximum": 2435.4492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1704.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1411090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-20      G00810",
      "code_information": [
        {
          "code": "1414825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.7704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOFILTER-ASP FLTR",
      "code_information": [
        {
          "code": "3002210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 508,
          "minimum": 173.6673,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 258.0589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR",
      "code_information": [
        {
          "code": "3002324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.9109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM        388.394",
      "code_information": [
        {
          "code": "3002383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 525.7696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         60-20385",
      "code_information": [
        {
          "code": "3002391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1102,
          "minimum": 376.7351,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 559.805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD DISP   8000-140",
      "code_information": [
        {
          "code": "3003251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 116.3297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-COLON CYTO        000110",
      "code_information": [
        {
          "code": "3003503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 161,
          "minimum": 55.0402,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.7864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND S03.000.009S",
      "code_information": [
        {
          "code": "3003841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 274.3146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO SMALL  1320-3042S",
      "code_information": [
        {
          "code": "3012204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1181,
          "minimum": 403.7424,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 599.9362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM       60-19326",
      "code_information": [
        {
          "code": "3012208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 564.8849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0           310.21",
      "code_information": [
        {
          "code": "3012318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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        {
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          "minimum": 332.2926,
          "maximum": 870.8526,
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              "payer_name": "Anthem",
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            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          310.288",
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        {
          "code": "0270",
          "type": "RC"
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        {
          "setting": "inpatient",
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          "minimum": 353.8301,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2           405883",
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        {
          "code": "3012341",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 375.3676,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDISPEC        SE-1",
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        {
          "code": "3012590",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 187.6838,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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      "service_type": "CDM"
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    {
      "description": "FORCEP-RJ4 LC BIOPSY 160CM",
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        {
          "code": "0270",
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        {
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          "minimum": 46.4936,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0MM 702460",
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 124.0969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDETHREAD 150MM  292.72",
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        {
          "code": "3016158",
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        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 157.5997,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CRESCENT         74-1010",
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        {
          "code": "3021150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 41.3656,
          "maximum": 870.8526,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE LF 022701",
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          "code": "3029356",
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
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          "minimum": 243.7496,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "PROBE-PIGTAIL 28-0174",
      "code_information": [
        {
          "code": "3034526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
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          "minimum": 364.0861,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "PROBE-LAPAROSCOPIC 5MM  160655",
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          "type": "LOCAL"
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        {
          "code": "0270",
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        {
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          "minimum": 393.4865,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM BLUE         XR60B",
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        {
          "code": "3039920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 175.7185,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
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      "service_type": "CDM"
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    {
      "description": "RESTRAINT-HEAD UNIV     050602",
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          "code": "3040461",
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        },
        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 104.6106,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCISSORS-ENDODUT METZ     3142",
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        {
          "code": "3044930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 157.2578,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY ALL 351-3000'sS",
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        {
          "code": "3049750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 ORBIT 7205323",
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        {
          "code": "3058626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 217.7679,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I KNIFE SURG 8065921552",
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        {
          "code": "3058653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 33.1609,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN LITE FUD023",
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        {
          "code": "3058869",
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        },
        {
          "code": "0270",
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      ],
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        {
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          "minimum": 26.3236,
          "maximum": 870.8526,
          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-HEEL PRESSURE MDT825",
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        {
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        },
        {
          "code": "0270",
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 132.6436,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION LARGE",
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        {
          "code": "3059275",
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
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          "minimum": 92.9872,
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SWANSON SUTURE  11-0675",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 339.1299,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 503.9261,
              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-RETRACTO 12\\\" 1041",
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        {
          "code": "3060247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 39.9982,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 59.4348,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH      SZ5  A0A04",
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        {
          "code": "3060306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 89.2267,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-4.5 AGGRESSIVE",
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        {
          "code": "3079259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 306.3109,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-VACURRETTE 5MM       21664",
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        {
          "code": "3083764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 31.1097,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-TUNNELING            1112",
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        {
          "code": "3084399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 179.4791,
          "maximum": 870.8526,
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INFLATION   03.804.413S",
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          "code": "3084946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 392.8027,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 583.6805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12X100MM     H12LP",
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        {
          "code": "3085208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 702,
          "minimum": 239.9891,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SPIKE INFILTRATION",
      "code_information": [
        {
          "code": "3085534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX 116230",
      "code_information": [
        {
          "code": "3085546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 321.353,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 477.5106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM PROX",
      "code_information": [
        {
          "code": "3085796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 676,
          "minimum": 231.1006,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 343.4012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM VAS          XR30V",
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        {
          "code": "3086955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 443,
          "minimum": 151.4461,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 225.0396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.8MM        292.68",
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        {
          "code": "3091218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 623,
          "minimum": 212.9818,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 316.4778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT COLUMN 470341",
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        {
          "code": "3115590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 96.4059,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SYRINGE SSS-STP-SP",
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        {
          "code": "3500008",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 85.3423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-LARYNGOSCOPE DISP",
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        {
          "code": "3518940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 51.815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POLYLOOP-LIGATING DEVICE HX-40",
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        {
          "code": "3526123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 330.2415,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 490.7183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BASIC BREAST DYNJ60139",
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        {
          "code": "3526420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 403.4005,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 599.4282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR HEAD/NECK",
      "code_information": [
        {
          "code": "3526670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 377,
          "minimum": 128.8831,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.5122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SUCTION 12.7 HI CAPACITY",
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        {
          "code": "3527060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 23.2468,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.5433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-BIOPSY MARQUEE",
      "code_information": [
        {
          "code": "3527097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 266.3127,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 395.7242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-ACOUSTIC RESPIRATION",
      "code_information": [
        {
          "code": "3541329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 337,
          "minimum": 115.2085,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 171.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION OSTOMY BX 1500H",
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        {
          "code": "3542454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.6653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ1",
      "code_information": [
        {
          "code": "3548009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 121,
          "minimum": 41.3656,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.4668,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KCLAB2C",
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        {
          "code": "3549038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 183,
          "minimum": 62.5613,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.9622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-BASIC HEEL PRESSURE",
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        {
          "code": "3549107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 115.2085,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 171.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULAIDE-CPAP SIZE 2, CA102-",
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        {
          "code": "3549182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 56.7496,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 84.3263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HUMIDIFIER ATSVII BE-1010",
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        {
          "code": "3549307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5M SHORT 6149.1037",
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        {
          "code": "3549352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD BK-IS 109185",
      "code_information": [
        {
          "code": "3549411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 561,
          "minimum": 191.7862,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 284.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE HINGED DONJOY",
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        {
          "code": "3549781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 298.1062,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 442.9673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL SINGLE PK 1",
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        {
          "code": "3549805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 339.1299,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 503.9261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.6X30 SPEED 703894",
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        {
          "code": "3550046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 937,
          "minimum": 320.3274,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 475.9866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST ALL SIZE 9105-00s",
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        {
          "code": "3550085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 50.291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X25MM 7005-3325",
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        {
          "code": "3550159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 303.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STATLOCK-URO FOLEY FOL0105",
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        {
          "code": "3550423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER",
      "code_information": [
        {
          "code": "3550432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 327.6535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153207",
      "code_information": [
        {
          "code": "3550599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXYTYKE INFNT W/7’ TUBING",
      "code_information": [
        {
          "code": "3550754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 73,
          "minimum": 24.9561,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.0833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0X150MM 705234",
      "code_information": [
        {
          "code": "3550888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 903,
          "minimum": 308.704,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4.5MM 080-453",
      "code_information": [
        {
          "code": "3559003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.6493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPREADER-SILIPOS GEL TOE MED",
      "code_information": [
        {
          "code": "3559185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.6712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 116239",
      "code_information": [
        {
          "code": "3559543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1039,
          "minimum": 355.1976,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 527.8016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-DRESSING CHANGE 4D",
      "code_information": [
        {
          "code": "3571200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.4702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE RCM-14815",
      "code_information": [
        {
          "code": "3598048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 839,
          "minimum": 286.8246,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 426.2036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-REINFUSION SB1E",
      "code_information": [
        {
          "code": "3598227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 157.9849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-Z-FLO FLUID",
      "code_information": [
        {
          "code": "3598273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 441,
          "minimum": 150.7624,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 224.0236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 22GX.75\\\"",
      "code_information": [
        {
          "code": "3598320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.5627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHEST-DRAIN 4050-100N",
      "code_information": [
        {
          "code": "3598393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 477,
          "minimum": 163.0695,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 242.3112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION SZ:8",
      "code_information": [
        {
          "code": "3598398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 117.2596,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 174.2406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISTAL DUODENOVIDEOSCOPE",
      "code_information": [
        {
          "code": "3598674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Suture-7-0 Prolene Blue 8704H",
      "code_information": [
        {
          "code": "3598759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.6653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR PAPERELLA 510-043C",
      "code_information": [
        {
          "code": "3598871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 220,
          "minimum": 75.2103,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.7578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X3.5MM AR-8741-14",
      "code_information": [
        {
          "code": "3600715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 309.3659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-12\\\" THD AR-8967KT-12",
      "code_information": [
        {
          "code": "3601044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.0042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CHEST VENT HYFIN TWINPACK",
      "code_information": [
        {
          "code": "3601126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.8823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 150MM 4933-1-150",
      "code_information": [
        {
          "code": "3601246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 527,
          "minimum": 180.1628,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 267.7107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC LARGE 313-9015W",
      "code_information": [
        {
          "code": "3601352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 283,
          "minimum": 96.7478,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.7612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-3X7 AR-9300DS",
      "code_information": [
        {
          "code": "3601434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 827,
          "minimum": 282.7222,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 420.1077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON PEG ENFIT",
      "code_information": [
        {
          "code": "3601438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 97,
          "minimum": 33.1609,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN 2.55MM MD 45303155",
      "code_information": [
        {
          "code": "3601456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.3416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TROCH 1.35MM AR-8737-02",
      "code_information": [
        {
          "code": "3601814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.5089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .045X5\\\" 5050-248",
      "code_information": [
        {
          "code": "3601940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 103,
          "minimum": 35.2121,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXT-PERCUTANEOUS 9009",
      "code_information": [
        {
          "code": "3601976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 509.514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED A/B",
      "code_information": [
        {
          "code": "3602055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-ORGO IRRIGATION 1502152",
      "code_information": [
        {
          "code": "3602107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.5854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HAWKINS 18GX15CM G05045",
      "code_information": [
        {
          "code": "3602657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.5989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X250 AO 1806-8018S",
      "code_information": [
        {
          "code": "3602902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1150,
          "minimum": 393.1446,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 584.1885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.35MM AR-5050-01",
      "code_information": [
        {
          "code": "3603040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOVIE-E-Z CLEAN 0014A",
      "code_information": [
        {
          "code": "3603224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.0992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 VICRYL PLUS VCP762D",
      "code_information": [
        {
          "code": "3603378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 108.7099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.9X27MM 60-19126",
      "code_information": [
        {
          "code": "3603820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1112,
          "minimum": 380.1537,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 564.8849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y415H",
      "code_information": [
        {
          "code": "3603838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6.0959,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE 1.4MM 57S90004",
      "code_information": [
        {
          "code": "3603902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 645,
          "minimum": 220.5028,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 327.6535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SPO2 ADULT NR37004030",
      "code_information": [
        {
          "code": "3603929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.1472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 18FR BE6050",
      "code_information": [
        {
          "code": "3603961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1191,
          "minimum": 407.161,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 605.0161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CIRCUMCISION 1.45CM",
      "code_information": [
        {
          "code": "3604060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 605,
          "minimum": 206.8282,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 307.3339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VICRYL VCP104G",
      "code_information": [
        {
          "code": "3604215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 160,
          "minimum": 54.6984,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.2784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MINITAPE-LOOPED 72205435",
      "code_information": [
        {
          "code": "3604218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 913,
          "minimum": 312.1226,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 463.7949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 6X7 AR-6535TD",
      "code_information": [
        {
          "code": "3604297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 401,
          "minimum": 137.0878,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 203.704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7/F 2.4 AR-8916-18",
      "code_information": [
        {
          "code": "3604317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 272.7906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-NYLON 11MM/265ML CD005",
      "code_information": [
        {
          "code": "3604438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 333.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/2 DS28",
      "code_information": [
        {
          "code": "3604571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 815,
          "minimum": 278.6199,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 414.0118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-33MM LF EVERGRIP33",
      "code_information": [
        {
          "code": "3604594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 359,
          "minimum": 122.7295,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 182.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE    16G X 12.5",
      "code_information": [
        {
          "code": "1410723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 103.9907,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM         310.44",
      "code_information": [
        {
          "code": "3002798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 25.5806,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 125ML 04251",
      "code_information": [
        {
          "code": "3003421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 285.2793,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPORT II PAL-406LS",
      "code_information": [
        {
          "code": "3004250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 3.2X300MM",
      "code_information": [
        {
          "code": "3014238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 124.5664,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE  2839-xx-xxx",
      "code_information": [
        {
          "code": "3027302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 268.0402,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-TRIMANO BEACH CHAIR",
      "code_information": [
        {
          "code": "3034325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 11 G06732",
      "code_information": [
        {
          "code": "3059264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-4.5MM INCISOR PLUS",
      "code_information": [
        {
          "code": "3060481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30BL      TX30B",
      "code_information": [
        {
          "code": "3081557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 50.6051,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER   60-6085-20x",
      "code_information": [
        {
          "code": "3145100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3521005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 143.4738,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSDUCER TRUWAVE PX272",
      "code_information": [
        {
          "code": "3526526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 99.5419,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLOWSAFE II",
      "code_information": [
        {
          "code": "3549715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 56.7222,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-TRANSFUSION EXCHANGE",
      "code_information": [
        {
          "code": "3571501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 210.2058,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR CARE XL MULTI-USE",
      "code_information": [
        {
          "code": "3598079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/SHOULDER WRAP",
      "code_information": [
        {
          "code": "3598181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 207.4253,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 10ML GIS-59",
      "code_information": [
        {
          "code": "3599411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 265.8158,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPAP BUBBLE MR290 CHAMBER",
      "code_information": [
        {
          "code": "3599616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 162.9373,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G ACCESS 03.804.517S",
      "code_information": [
        {
          "code": "3600911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 153.4836,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300S NTHRD 702463S",
      "code_information": [
        {
          "code": "3602409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 58.3905,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL",
      "code_information": [
        {
          "code": "3602464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 231.8937,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANTENNA-PROGRAMMER       37092",
      "code_information": [
        {
          "code": "3000651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1212.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        310.111",
      "code_information": [
        {
          "code": "3002241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2       AR-8944-22",
      "code_information": [
        {
          "code": "3002251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0          316.396",
      "code_information": [
        {
          "code": "3002271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1875.7253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM         310.31",
      "code_information": [
        {
          "code": "3002300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 913.1162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM         310.11",
      "code_information": [
        {
          "code": "3002784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2767.1536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM         310.26",
      "code_information": [
        {
          "code": "3002788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DISSECT ELECTRODE 139330",
      "code_information": [
        {
          "code": "3002955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW             511.9xxS",
      "code_information": [
        {
          "code": "3003266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS  03.000.3xxS",
      "code_information": [
        {
          "code": "3003268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 532.066S",
      "code_information": [
        {
          "code": "3003293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 225 ML04253",
      "code_information": [
        {
          "code": "3003420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 4MM PAL-404LLB",
      "code_information": [
        {
          "code": "3004044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-304LLB",
      "code_information": [
        {
          "code": "3004046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO PAL-304LM",
      "code_information": [
        {
          "code": "3004053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 5832.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHOLANGIOGRAM       C100",
      "code_information": [
        {
          "code": "3005220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR TITANIUM  FV012T",
      "code_information": [
        {
          "code": "3009771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3          316.402",
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        {
          "code": "0270",
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              "payer_name": "Anthem",
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          ]
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    {
      "description": "BIT-DRILL 3.5MM AR-4160-35",
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        {
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          "setting": "inpatient",
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    {
      "description": "BIT-DRILL              310.141",
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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    {
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              "payer_name": "Anthem",
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    {
      "description": "LOOP-CUTTING 24FR      880-213",
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    {
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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      "description": "BIT-DRILL 2.5MM AR-8943-",
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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            {
              "payer_name": "Anthem",
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    {
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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        }
      ],
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              "payer_name": "Anthem",
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        }
      ],
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    },
    {
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
      "description": "KIT-INSERTION 16/18 FR 96551",
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              "payer_name": "Anthem",
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            }
          ]
        }
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    },
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
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        {
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DELIVERY NAVIFLEX 7FR.",
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          "type": "LOCAL"
        },
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE ARTERIAL ART356",
      "code_information": [
        {
          "code": "3602029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2020.3113,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION PD-IT",
      "code_information": [
        {
          "code": "3602078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1059.9266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OIL-BIENAIR LUBRIFLUID 1600064",
      "code_information": [
        {
          "code": "3602105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE 16G X 16.5",
      "code_information": [
        {
          "code": "3602125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2613.67,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 8657.9209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 914.2284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREDED AR-18800-11T",
      "code_information": [
        {
          "code": "3602495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 2487.9914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-5 MREYE G36405",
      "code_information": [
        {
          "code": "3602688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-3 MREYE G42419",
      "code_information": [
        {
          "code": "3602689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 3189.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G BVL 0306-331-000",
      "code_information": [
        {
          "code": "3603302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 1474.2211,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE -.9MM AR-7524C",
      "code_information": [
        {
          "code": "3604464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 980.4043,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DBL 4X30/10 PAL-405LL",
      "code_information": [
        {
          "code": "3604617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-8x30/8 PAL-402LL",
      "code_information": [
        {
          "code": "3604619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 649.5015,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 895,
          "minimum": 305.969,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 454.651,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 J305H",
      "code_information": [
        {
          "code": "3012910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 27745.4973,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL3-0 27\\\" FS-2",
      "code_information": [
        {
          "code": "3033304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 45.6002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-ETHICON         PCP-20",
      "code_information": [
        {
          "code": "3033960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 831.3695,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUT-PDS 2-0 Z317H",
      "code_information": [
        {
          "code": "3059073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 2682.0703,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VIC 2-0           J317H",
      "code_information": [
        {
          "code": "3088957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J329H",
      "code_information": [
        {
          "code": "3088960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 101.2102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y215H",
      "code_information": [
        {
          "code": "3088973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y214H",
      "code_information": [
        {
          "code": "3088974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-RETENTION 450G",
      "code_information": [
        {
          "code": "3088984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 36\\\"        Z346H",
      "code_information": [
        {
          "code": "3088987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y398H",
      "code_information": [
        {
          "code": "3088989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 59.5027,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J602H",
      "code_information": [
        {
          "code": "3088995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 296.4013,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y346H",
      "code_information": [
        {
          "code": "3088999",
          "type": "LOCAL"
        },
        {
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    },
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    {
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    {
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    {
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    {
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    {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A305H",
      "code_information": [
        {
          "code": "3089185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A185H",
      "code_information": [
        {
          "code": "3089186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K831H",
      "code_information": [
        {
          "code": "3089193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 46.7124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0           684H",
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        {
          "code": "3089198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          A183H",
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        {
          "code": "3089200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 65.6198,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        636H",
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        {
          "code": "3089205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X964H",
      "code_information": [
        {
          "code": "3089208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 39.4831,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2        X519H",
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        {
          "code": "3089213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X518H",
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        {
          "code": "3089214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0       1674H",
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        {
          "code": "3089236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 4.7861,
          "maximum": 37.8148,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1673H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        627H",
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        {
          "code": "3089245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z339H",
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        {
          "code": "3089255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 36.1465,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0   Z304H",
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        {
          "code": "3089260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J442H",
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        {
          "code": "3089274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 1689H",
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        {
          "code": "3089276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            SA87G",
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        {
          "code": "3089277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2          J880T",
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        {
          "code": "3089278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2          460T",
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        {
          "code": "3089298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J214H",
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        {
          "code": "3089329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 144.0299,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J662H",
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        {
          "code": "3089339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL 1          J347H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 4.7861,
          "maximum": 106.7712,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J335H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X425H",
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        {
          "code": "3089385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 205.757,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z333H",
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        {
          "code": "3089395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 131.2396,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 626H",
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        {
          "code": "3089409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 4.7861,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685H",
      "code_information": [
        {
          "code": "3500610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 166.2739,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    684G",
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        {
          "code": "3500770",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 88.4199,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          K872H",
      "code_information": [
        {
          "code": "3501015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 18FR 30CC      266718",
      "code_information": [
        {
          "code": "3507735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 42.8197,
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 0 PDP340H",
      "code_information": [
        {
          "code": "3526247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 5380.8236,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-3-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 42.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-3-0 PLUS",
      "code_information": [
        {
          "code": "3526254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 1 PDP341H",
      "code_information": [
        {
          "code": "3549733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 1474.2211,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 4-0 R633H",
      "code_information": [
        {
          "code": "3549987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 2490.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        635G",
      "code_information": [
        {
          "code": "3555389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           622-H",
      "code_information": [
        {
          "code": "3557329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK O             624H",
      "code_information": [
        {
          "code": "3557386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            K834H",
      "code_information": [
        {
          "code": "3557388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           661-G",
      "code_information": [
        {
          "code": "3557535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           662-G",
      "code_information": [
        {
          "code": "3557568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           663-H",
      "code_information": [
        {
          "code": "3557592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 2.0        664G",
      "code_information": [
        {
          "code": "3557990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON            801H",
      "code_information": [
        {
          "code": "3558467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 47.8246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 3-0        1671-H",
      "code_information": [
        {
          "code": "3559001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 580.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         B-842-H",
      "code_information": [
        {
          "code": "3560064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH CHROMIC 3-0 G-122-H",
      "code_information": [
        {
          "code": "3560211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J219H",
      "code_information": [
        {
          "code": "3560487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J258H",
      "code_information": [
        {
          "code": "3560490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-259-H",
      "code_information": [
        {
          "code": "3560505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL          J-416-H",
      "code_information": [
        {
          "code": "3560745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 46.1563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J415H",
      "code_information": [
        {
          "code": "3560840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 32.8099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J417H",
      "code_information": [
        {
          "code": "3561410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 107.8834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        669H",
      "code_information": [
        {
          "code": "3561418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 3-0  J-944-H",
      "code_information": [
        {
          "code": "3561419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 10.1598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 4.7861,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-833-H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "maximum": 37.8148,
          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH MONOCRL 2-0   Y259H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 51.1612,
          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3.0    Y-338-H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        }
      ],
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        {
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
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      "standard_charges": [
        {
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          "maximum": 55.0539,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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          "code": "0270",
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        }
      ],
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            }
          ]
        }
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    },
    {
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        },
        {
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        }
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 4.7861,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
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    },
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        }
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP945G",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "inpatient",
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          "payers_information": [
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 J422H",
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        {
          "code": "3598401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL SZ 1 36\\\" J519H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS #1 VCP371H",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 G181H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 4.7861,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1670H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 4.7861,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL+ #1 VCP569H",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 4.7861,
          "maximum": 33.9221,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 32.2538,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 4.7861,
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
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    },
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        },
        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP305H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 4.7861,
          "maximum": 161.8251,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP422H",
      "code_information": [
        {
          "code": "3604226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 8281.4412,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP218H",
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        {
          "code": "3604353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 4.7861,
          "maximum": 5822.367,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 4-0 VCP434H",
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        {
          "code": "3604548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 14,
          "minimum": 4.7861,
          "maximum": 199.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-TOUHY BORST W/SIDE ARM",
      "code_information": [
        {
          "code": "1410050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1049.3607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-FEMORAL ANGIO  DYNJP4119",
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        {
          "code": "1410800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 1343.5376,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18GX10CM   G01559",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-15      G03955",
      "code_information": [
        {
          "code": "1410919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CLOSED NEEDLE  LNGC-2022",
      "code_information": [
        {
          "code": "1495266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 9G EVIVA",
      "code_information": [
        {
          "code": "1495267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SWIVEL PORTEX 625191",
      "code_information": [
        {
          "code": "3002219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT ANT- 1012S",
      "code_information": [
        {
          "code": "3004017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-RANEY SCALP ADULT 20-1037",
      "code_information": [
        {
          "code": "3008833",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 6374.5743,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE       PMI-TC-SG",
      "code_information": [
        {
          "code": "3010072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 306.4111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE FUZZY       FZ624",
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        {
          "code": "3020107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 4593.9421,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LID-COLLECTION DISP    BKC-506",
      "code_information": [
        {
          "code": "3021629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2446.84,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SURGISAFE ABSORB WHITE",
      "code_information": [
        {
          "code": "3029216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-UNIVRSL I AURO DYNJP1050A",
      "code_information": [
        {
          "code": "3029269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 153.4836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 10CM    70890856",
      "code_information": [
        {
          "code": "3029291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-STENT 6FR M0061802011",
      "code_information": [
        {
          "code": "3038668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR MANIFOLD",
      "code_information": [
        {
          "code": "3050023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 5790.1132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 CX21D",
      "code_information": [
        {
          "code": "3058821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 1791.7542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TRU               2C4041",
      "code_information": [
        {
          "code": "3079241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 1851.2569,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COAG SUCTION      050-005",
      "code_information": [
        {
          "code": "3085551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ELECTROSURGICAL 8\\\"050-010",
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        {
          "code": "3085595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 860.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX OUTFLOW AQL-111",
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        {
          "code": "3086104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-3/8\\\"X3/32\\\"X8'     3508S",
      "code_information": [
        {
          "code": "3086137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 CX22D",
      "code_information": [
        {
          "code": "3089700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-AERO          58-79510",
      "code_information": [
        {
          "code": "3284351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHARMBER-HEATER MR290",
      "code_information": [
        {
          "code": "3290069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ENDO TUBE ANCHORFAST",
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        {
          "code": "3290137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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          "minimum": 61.1938,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-DERMABOND MINI",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SPIKE PRIMING   101593",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-HYPERINFLATION   1/2 LITER",
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        {
          "code": "3501291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
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          "payers_information": [
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CAPNOLINE 11996-000163",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
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          "minimum": 61.1938,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT TALL LF/ALUM 7704",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHANNEL ALL JP22xx",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 F/PEDS PEDICAP6",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL LRG     L-35MM",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM 10X7.5CM",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
          "maximum": 1634.934,
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEEDER-SPECIALNEEDS 80ML 6000S",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLD MIC 40M SQ40SK",
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        {
          "code": "3516131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE ALL SZS     N7s",
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          "code": "3519400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-KNEE 22\\\"   1220917",
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        {
          "code": "3519967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 61.1938,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7089-0844",
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        {
          "code": "3526221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 61.1938,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP839D",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP838",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 260.8109,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTOR-ADULT INTUBATED AIRWAY",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GROMMET-BEVELED VENT 70241350",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS INF-L",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DELIVER MORGAN LENS MT202",
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        {
          "code": "3541942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
          "maximum": 473.7972,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD/IV FLUID WARMER L-70",
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        {
          "code": "3542396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 150.7031,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM PREMIE N4901",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 24 JP-2234",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 3741.9969,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOCKS-TISSUE FLT-010",
      "code_information": [
        {
          "code": "3549777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 970.3945,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIRROR-INSPECTION DIABETIC 081",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 680.1103,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM INFANT N4902",
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        {
          "code": "3550255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 61.1938,
          "maximum": 534.4121,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVES-SKIL-CARE GERI SM 5669",
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        {
          "code": "3550329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF LG MDS601LD",
      "code_information": [
        {
          "code": "3550554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE,MERSILINE 4-0 S-2 1779G",
      "code_information": [
        {
          "code": "3550847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 438.2068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT ANES 2L 72\\\"",
      "code_information": [
        {
          "code": "3559130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP774D",
      "code_information": [
        {
          "code": "3559182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 31619.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-UNDER NOSE",
      "code_information": [
        {
          "code": "3559270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 417.075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 15 JP-2228",
      "code_information": [
        {
          "code": "3559392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 19 JP-2230",
      "code_information": [
        {
          "code": "3559393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-HUMIDIFER MR290V",
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        {
          "code": "3559432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 209.6497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET NEO",
      "code_information": [
        {
          "code": "3559609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 657.8663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         C-017-D",
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        {
          "code": "3560077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4258705",
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        {
          "code": "3568756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 211.318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-COBAN 2LAYER         2094",
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        {
          "code": "3575850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 180.7325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND UNIVERSAL RT/LT LG",
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        {
          "code": "3580012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIV 9006-00",
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        {
          "code": "3580022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
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        {
          "code": "3598026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MAC",
      "code_information": [
        {
          "code": "3598027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LAPAROSCOPIC STR 2190J",
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        {
          "code": "3598116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-POLY OVAL SOFT WIRE",
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        {
          "code": "3598262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 3764.2409,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ARTHROGRAM DYNJ07425",
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        {
          "code": "3598354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAG-DISP SUCT 10’ 30-5201",
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        {
          "code": "3598648",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 12882.0565,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1 VASC1346",
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        {
          "code": "3598865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/63-74\\\" 1146PP",
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        {
          "code": "3598976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-NASAL VIP1137380",
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        {
          "code": "3599139",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 149.5909,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-NASAL VIP1137381",
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        {
          "code": "3599142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 483.807,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE RENOVARP GIS-29",
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        {
          "code": "3599229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 61.1938,
          "maximum": 398.1676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 17-22CM",
      "code_information": [
        {
          "code": "3599603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 22-25CM",
      "code_information": [
        {
          "code": "3599604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 25-29CM",
      "code_information": [
        {
          "code": "3599605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 29-36CM",
      "code_information": [
        {
          "code": "3599606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 240014",
      "code_information": [
        {
          "code": "3599773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 836.9305,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SSL",
      "code_information": [
        {
          "code": "3600225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1MSL",
      "code_information": [
        {
          "code": "3600226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1LSL",
      "code_information": [
        {
          "code": "3600227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL WIDE EVO1WSL",
      "code_information": [
        {
          "code": "3600228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 132.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2SSL",
      "code_information": [
        {
          "code": "3600230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2MSL",
      "code_information": [
        {
          "code": "3600231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CN 10MM HEX P45-940-0001",
      "code_information": [
        {
          "code": "3600608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 378.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-JTIP .025X33CM",
      "code_information": [
        {
          "code": "3600780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 542.7536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP726D",
      "code_information": [
        {
          "code": "3601389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 696.7933,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SEDLINE RD",
      "code_information": [
        {
          "code": "3601706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMP SENSING 16FR 119216",
      "code_information": [
        {
          "code": "3601726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 865.2916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PREM CS006",
      "code_information": [
        {
          "code": "3601999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 2823.3197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 0 VCPP31D",
      "code_information": [
        {
          "code": "3602463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-INSTRUMENT T50106",
      "code_information": [
        {
          "code": "3603056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 12107.9653,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63447",
      "code_information": [
        {
          "code": "3603065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63446",
      "code_information": [
        {
          "code": "3603066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3603332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 7779.839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-BIOPSY ORT 27550ZAG/10",
      "code_information": [
        {
          "code": "3603541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG GOLD NR30001010",
      "code_information": [
        {
          "code": "3603912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NOMOLINE LH AIRWAY ADAPTER",
      "code_information": [
        {
          "code": "3603959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 662.3151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED W/ PEEP VALVE",
      "code_information": [
        {
          "code": "3603963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADULT W/ PEEP VAL",
      "code_information": [
        {
          "code": "3603964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION C2202",
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        {
          "code": "3603996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 6010.3288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP840D",
      "code_information": [
        {
          "code": "3604214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 61.1938,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY METER ALL P4PxxULD",
      "code_information": [
        {
          "code": "3084872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 50.049,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8702H",
      "code_information": [
        {
          "code": "3089122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 58.9466,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          JJ31G",
      "code_information": [
        {
          "code": "3089143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C016D",
      "code_information": [
        {
          "code": "3089188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 6-0          1732G",
      "code_information": [
        {
          "code": "3089203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 35.5904,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX41",
      "code_information": [
        {
          "code": "3089216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 60.6149,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J840D",
      "code_information": [
        {
          "code": "3089388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 54.4978,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ9 8.5CM",
      "code_information": [
        {
          "code": "3311077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 47.8246,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PULLEY-OVERDOOR LUM101P",
      "code_information": [
        {
          "code": "3311351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 39.4831,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LTA MADGIC       MAD600",
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        {
          "code": "3512793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 37.8148,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 J864D",
      "code_information": [
        {
          "code": "3526246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 7.7854,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 8X18",
      "code_information": [
        {
          "code": "3526255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 31.1416,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS NEO-L",
      "code_information": [
        {
          "code": "3541327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 30.0294,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH MALE EXTERNAL MECSB01",
      "code_information": [
        {
          "code": "3550510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 33.9221,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 S-14",
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        {
          "code": "3559177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 37.8148,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2350H",
      "code_information": [
        {
          "code": "3559280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 57.8344,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 1 VCP741D",
      "code_information": [
        {
          "code": "3598416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 45.0441,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NERVE BLOCK 22G HN3S-80",
      "code_information": [
        {
          "code": "3598440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 36.1465,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2LSL",
      "code_information": [
        {
          "code": "3600232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 31.1416,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63445",
      "code_information": [
        {
          "code": "3603067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 55.0539,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE PMITCSG",
      "code_information": [
        {
          "code": "3603191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 179,
          "minimum": 41.1514,
          "maximum": 129.9003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER TOP 44X44 ORS-100",
      "code_information": [
        {
          "code": "3011925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 126.7908,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT         PI-104",
      "code_information": [
        {
          "code": "3019880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 55.0539,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 2xFR",
      "code_information": [
        {
          "code": "3058922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 44.488,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 16\\\" 7716-000-10",
      "code_information": [
        {
          "code": "3060133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 56.1661,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNELER 16G     ACC10S",
      "code_information": [
        {
          "code": "3079464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 76.7418,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SEPTAL NEIMAN  14-0441",
      "code_information": [
        {
          "code": "3080203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 67.8442,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMDxx40x",
      "code_information": [
        {
          "code": "3082490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 38.927,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-EYE 10.0          7711G",
      "code_information": [
        {
          "code": "3082557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 35.5904,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXMP1B117",
      "code_information": [
        {
          "code": "3089421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 99.5419,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 3.2MM        702462",
      "code_information": [
        {
          "code": "3091254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 99.5419,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBIGRIP D 1437",
      "code_information": [
        {
          "code": "3503055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 105.1029,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH X3-003-000",
      "code_information": [
        {
          "code": "3504921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 93.9809,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 600ML 622278",
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        {
          "code": "3505722",
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        {
          "code": "0270",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC FREEDOM 300ML",
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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          ]
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      "service_type": "CDM"
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    {
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        {
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 94.537,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC ALL SZ",
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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    {
      "description": "CIRCUIT-OXYLOG 3000 DISPOSABLE",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 80.0784,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COLLECTN BREAST MILK  67's",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 40.0392,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
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      ],
      "service_type": "CDM"
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    {
      "description": "SENSORMAT-CHAIR-CHEC 65815-030",
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        {
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          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
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              "methodology": "percent of total billed charges",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 5FR TMI      1154",
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        {
          "code": "3541914",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR A3",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION A495LM",
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          "code": "3559184",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PROCEDURE PICC W/O PICC",
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        {
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 102.3224,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 18GA    9001C0212",
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        {
          "code": "3590035",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 62.8393,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-POLAR KNEE WRAP-ON",
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        {
          "code": "3598080",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 96.7614,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BONE MARROW 11GX4\\\" BAK451",
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        {
          "code": "3598402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 35.5904,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM BLADED CTB73",
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        {
          "code": "3598438",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 60.6149,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL EVF1XMLSLA",
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        {
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        },
        {
          "code": "0270",
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      ],
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        {
          "setting": "inpatient",
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          "minimum": 99.5419,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "PADS-LACURA VISCO FOOT",
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        {
          "code": "0270",
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      ],
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        {
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          "minimum": 71.1808,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 7FR       06-107F",
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "maximum": 415.4067,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 MS-DC5020",
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          MS-DC28",
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        {
          "code": "3002372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DERMATOME 00-8800-000-10",
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        {
          "code": "3002650",
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        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-7.3 ARCH AORTIC MT022A",
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        {
          "code": "3004031",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHOULDER ALL AR-6500s",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS HIFLO 24F 69324",
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        {
          "code": "3004482",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR        12002",
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        {
          "code": "3004521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 898.1015,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-5MM PROT BLUE 5027-1050",
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        {
          "code": "3004650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 809.6816,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-34 DPSB DISP TOURNIQUET",
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        {
          "code": "3009958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-42 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 17613.3553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-UTERINE MANIPULATOR",
      "code_information": [
        {
          "code": "3019600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3551.2546,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MAGNUM BIOPSY    MN18xx",
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        {
          "code": "3027515",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 442.0995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-PERI-OB DRAPE       2997",
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        {
          "code": "3034345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-CANNULA XI      470381",
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        {
          "code": "3039883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 466.0118,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-SUTURE ASSISTANT  SW110",
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        {
          "code": "3039900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 479.3582,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETAINER-VISCERA LARGE HS-3206",
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        {
          "code": "3040486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 BV-1 BLUE EPH9702H",
      "code_information": [
        {
          "code": "3058802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 44501.9025,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL NEW",
      "code_information": [
        {
          "code": "3059210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN",
      "code_information": [
        {
          "code": "3059265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2961.2325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-VIA-GUARD SMP-2006-001",
      "code_information": [
        {
          "code": "3060015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 519.9535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THREADED 72200425",
      "code_information": [
        {
          "code": "3060484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 741.8374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-ELECTROLUBE         EL101",
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        {
          "code": "3078867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 697.3494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING           031229-10",
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        {
          "code": "3079239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-IRRIG SUCT 250070530",
      "code_information": [
        {
          "code": "3083086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 45CM     3909",
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        {
          "code": "3083636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-ONQ ALL         T1X's",
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        {
          "code": "3086215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS ADAPTER",
      "code_information": [
        {
          "code": "3087517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 1010030",
      "code_information": [
        {
          "code": "3088591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 300.8501,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 5        RS21",
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        {
          "code": "3089261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 337.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-BLUE VLOCN0615",
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        {
          "code": "3089401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             1101",
      "code_information": [
        {
          "code": "3093210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1368.5621,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS 420023",
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        {
          "code": "3155010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS LONG",
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        {
          "code": "3155020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION ADJ",
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        {
          "code": "3311604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD           KVL03",
      "code_information": [
        {
          "code": "3504920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 1L    622283",
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        {
          "code": "3505720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE A ARTERIAL    400115A",
      "code_information": [
        {
          "code": "3521984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 280.8305,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-KIWI OMNI SYSTEM",
      "code_information": [
        {
          "code": "3522453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 650.0809,
          "payers_information": [
            {
              "payer_name": "Anthem",
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    {
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        {
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    {
      "description": "KIT-PULSAVAC IRRIGATION",
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        {
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      "standard_charges": [
        {
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              "payer_name": "Anthem",
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        {
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        {
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    {
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        {
          "code": "0270",
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    {
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    {
      "description": "BOOT-HEEL SUSPENSION   M60-300",
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    {
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              "payer_name": "Anthem",
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              "payer_name": "Anthem",
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      "description": "BURR-DIAMOND 5MM 0227-010-250",
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    {
      "description": "INSERT-INTRACK ULTRA 66MM",
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        {
          "code": "0270",
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.4803,
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          ]
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              "payer_name": "Anthem",
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          ]
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              "payer_name": "Anthem",
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        }
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    {
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      ],
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              "payer_name": "Anthem",
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          ]
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    {
      "description": "KIT-DELUXE KNEE/HIP 081603273",
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              "payer_name": "Anthem",
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          ]
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      ],
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    },
    {
      "description": "SET-INTERPULSE HANDLE W TIP",
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        {
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          ]
        }
      ],
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    },
    {
      "description": "TROCAR-W/CANNULA 12MM ONB12STF",
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        {
          "code": "0270",
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      ],
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        {
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          ]
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      ],
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    },
    {
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            }
          ]
        }
      ],
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    {
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          "code": "0270",
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          ]
        }
      ],
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    },
    {
      "description": "SYSTEM-URI-CATH 3.5FR&5.0FR",
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          ]
        }
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          ]
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            }
          ]
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      ],
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        {
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF 7.0MM",
      "code_information": [
        {
          "code": "3573939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 625.6125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 8.0MM",
      "code_information": [
        {
          "code": "3590138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 15' 251015J",
      "code_information": [
        {
          "code": "3598139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4336.4678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMP2B401",
      "code_information": [
        {
          "code": "3598157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 6183.2759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER PAD F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 539.9731,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH 5FR TMI1185",
      "code_information": [
        {
          "code": "3598221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 21028.3654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSPAC TRIFURCATED 42800",
      "code_information": [
        {
          "code": "3598244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 331.9917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4X70/16MM 607470",
      "code_information": [
        {
          "code": "3598460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 314.7526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 GORE-TEX 4N10B",
      "code_information": [
        {
          "code": "3598958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1007.6532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 18 FR",
      "code_information": [
        {
          "code": "3599116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 16 FR",
      "code_information": [
        {
          "code": "3599117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3490.6397,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-NITINOL PILOT 5901-6072",
      "code_information": [
        {
          "code": "3599187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/25CM MN1825",
      "code_information": [
        {
          "code": "3599317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4392.0778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSIONS-CABLE DISP 4051L",
      "code_information": [
        {
          "code": "3599647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 4002.8078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.1CM",
      "code_information": [
        {
          "code": "3600164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 336.4405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.6X150MM P99-292-1615",
      "code_information": [
        {
          "code": "3600326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 900.3259,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-CAPTURA DISP G53006",
      "code_information": [
        {
          "code": "3600504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 989.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-192-2330",
      "code_information": [
        {
          "code": "3600521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TENNIS RACQUET 5FR/90CM",
      "code_information": [
        {
          "code": "3600554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 989.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ 3",
      "code_information": [
        {
          "code": "3600778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 28621.9109,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-2.0X200MM P99-192-2020",
      "code_information": [
        {
          "code": "3601106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1091.6243,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,GASTRO MIC",
      "code_information": [
        {
          "code": "3601451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 876.9697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MIAR 14G 7FR 11014L",
      "code_information": [
        {
          "code": "3601478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 283.611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-OSIA OSI200 P1291019",
      "code_information": [
        {
          "code": "3601610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300 NTHRD 702463",
      "code_information": [
        {
          "code": "3601870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-193-2323",
      "code_information": [
        {
          "code": "3602140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.1MM AR-8655K-11",
      "code_information": [
        {
          "code": "3602154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SHEATH W/CATH SA-09847",
      "code_information": [
        {
          "code": "3602436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PT PUMP 8\\\"\\\" AR-6421",
      "code_information": [
        {
          "code": "3602461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2892.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-RING 16\\\" DUR8016W",
      "code_information": [
        {
          "code": "3602526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.2X150 TH P99-193-1215",
      "code_information": [
        {
          "code": "3602570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 9373.0655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP TRB29-LRG",
      "code_information": [
        {
          "code": "3602758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 3136.9601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.0X200MM P99-193-2020",
      "code_information": [
        {
          "code": "3602993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 877.5258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X100MM P99-192-1410",
      "code_information": [
        {
          "code": "3603370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-BIVENTRICULAR BS-101-97",
      "code_information": [
        {
          "code": "3603546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 3-0 PS-2",
      "code_information": [
        {
          "code": "3603921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.4X15 MSG14150",
      "code_information": [
        {
          "code": "3604046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.6X15 MSG16150",
      "code_information": [
        {
          "code": "3604056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 7516.2476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X150MM P99-292-0915",
      "code_information": [
        {
          "code": "3604177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X150 SM P99-192-2315",
      "code_information": [
        {
          "code": "3604181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-292-1115",
      "code_information": [
        {
          "code": "3604182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1615",
      "code_information": [
        {
          "code": "3604183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1415",
      "code_information": [
        {
          "code": "3604184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 2618.6749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-U-FRAME STRD MT-APU-2.4",
      "code_information": [
        {
          "code": "3604229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 868.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-HEX 10MM 76-10185",
      "code_information": [
        {
          "code": "3604312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-GUARDIAN HEMOSTAT 8215",
      "code_information": [
        {
          "code": "3604336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 519.3974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-WASTE 04369",
      "code_information": [
        {
          "code": "3604367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 7227.6317,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K .9X150MM P99-192-0915",
      "code_information": [
        {
          "code": "3604377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 870.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG 900-152",
      "code_information": [
        {
          "code": "3604585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD-EX 900-154",
      "code_information": [
        {
          "code": "3604586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD 900-151",
      "code_information": [
        {
          "code": "3604587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG-SHL 900-155",
      "code_information": [
        {
          "code": "3604588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FINGER SMALL 9906",
      "code_information": [
        {
          "code": "3604630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 373,
          "minimum": 127.5156,
          "maximum": 270.6861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.4803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "1100160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYN            ALLSZs",
      "code_information": [
        {
          "code": "1100275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC PED 10FR    8010",
      "code_information": [
        {
          "code": "1102034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 68.1678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 12FR PEDS   8012",
      "code_information": [
        {
          "code": "1102046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK BABY",
      "code_information": [
        {
          "code": "1102135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.6411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC 3-LUMEN PWR INJ SAFET",
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        {
          "code": "1110365",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 393.1182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH LUMEN 4FR    AK-14402",
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        {
          "code": "1110376",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 19G X .75",
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        {
          "code": "1113245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS          G04153",
      "code_information": [
        {
          "code": "1113258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 221.4173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-FOREIGN BODY   FB-5000",
      "code_information": [
        {
          "code": "1115735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 837,
          "minimum": 175.77,
          "maximum": 612.8514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEONATE TUBE RESV",
      "code_information": [
        {
          "code": "1115845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATHETER CRICOTHYROTOMY",
      "code_information": [
        {
          "code": "1118135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1639,
          "minimum": 344.19,
          "maximum": 1200.0758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 840.0531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-HANGING CAST LG 1180LPP",
      "code_information": [
        {
          "code": "1118520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "1118720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "1118735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "#1855G 5-0 ETHILON PC-1",
      "code_information": [
        {
          "code": "1118792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 49,
          "minimum": 10.29,
          "maximum": 35.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 25.1145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EVAC/DRAIN 1-BTL  62287",
      "code_information": [
        {
          "code": "1118801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED       8CFN",
      "code_information": [
        {
          "code": "1118955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 339,
          "minimum": 71.19,
          "maximum": 248.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 173.7511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
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        {
          "code": "1119001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 41,
          "minimum": 8.61,
          "maximum": 30.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 21.0141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
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        {
          "code": "1119800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 48,
          "minimum": 10.08,
          "maximum": 35.1456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 24.6019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-15      G00012",
      "code_information": [
        {
          "code": "1410067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINL 22X20     G03542",
      "code_information": [
        {
          "code": "1410472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 256,
          "minimum": 53.76,
          "maximum": 187.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.2102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CUSTOM WASTE BAG",
      "code_information": [
        {
          "code": "1410792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-INDIGO W/TUBING IAPS2",
      "code_information": [
        {
          "code": "1410803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1238.2966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INFUSION MRI          1056",
      "code_information": [
        {
          "code": "1410839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE ADAPTER MRI   1057",
      "code_information": [
        {
          "code": "1410840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 108.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18G 20CM   G01047",
      "code_information": [
        {
          "code": "1410918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 80.9813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1411090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18-15      G03954",
      "code_information": [
        {
          "code": "1411193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.2212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MONOPTY 18X10    121810",
      "code_information": [
        {
          "code": "1411612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.7871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JAR-COPLIN PP STAIN     S90130",
      "code_information": [
        {
          "code": "1411903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION     CID-20-30",
      "code_information": [
        {
          "code": "1412310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 734,
          "minimum": 154.14,
          "maximum": 537.4348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 376.2044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE .010-.038   TD01",
      "code_information": [
        {
          "code": "1412325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-STAYFIX SMALL    680-ME",
      "code_information": [
        {
          "code": "1412330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.4688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL IV 6FR   48-152",
      "code_information": [
        {
          "code": "1412380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL ALL 48-100's",
      "code_information": [
        {
          "code": "1412394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX ALL SZ",
      "code_information": [
        {
          "code": "1413165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 302.9111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX ALL SZ",
      "code_information": [
        {
          "code": "1413170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 523,
          "minimum": 109.83,
          "maximum": 382.9406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 268.0584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-20      G00810",
      "code_information": [
        {
          "code": "1414825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN ALL SZS G01xxx",
      "code_information": [
        {
          "code": "1414845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY ALL SZS",
      "code_information": [
        {
          "code": "1414866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-10      G01112",
      "code_information": [
        {
          "code": "1414935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "1414990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 116.8591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X     C20xxA",
      "code_information": [
        {
          "code": "1414995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.0707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-IV SILVERSITE 1X7MM",
      "code_information": [
        {
          "code": "1415449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT GASTRO INITIAL SM",
      "code_information": [
        {
          "code": "1415943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 987,
          "minimum": 207.27,
          "maximum": 722.6814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 505.877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-150 ML ILLUMENA 900103",
      "code_information": [
        {
          "code": "1416100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGIOGRAPHY    MCBK001-07",
      "code_information": [
        {
          "code": "1416236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 783,
          "minimum": 164.43,
          "maximum": 573.3126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 401.3188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22FR   0250-22",
      "code_information": [
        {
          "code": "1416370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENTUIT THRIVE 14F",
      "code_information": [
        {
          "code": "1416371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 713,
          "minimum": 149.73,
          "maximum": 522.0586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 365.441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-INDIGO             IST3",
      "code_information": [
        {
          "code": "1416377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2920,
          "minimum": 613.2,
          "maximum": 2138.024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1496.6168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1419101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.3922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX11C",
      "code_information": [
        {
          "code": "1419112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX15C",
      "code_information": [
        {
          "code": "1419113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 20GX15C",
      "code_information": [
        {
          "code": "1419114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX11C",
      "code_information": [
        {
          "code": "1419116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX15C",
      "code_information": [
        {
          "code": "1419118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 601,
          "minimum": 126.21,
          "maximum": 440.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 308.0365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX20C",
      "code_information": [
        {
          "code": "1419119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 601,
          "minimum": 126.21,
          "maximum": 440.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 308.0365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY  20GX11C",
      "code_information": [
        {
          "code": "1419293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 451,
          "minimum": 94.71,
          "maximum": 330.2222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 231.1555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-BIOPSY EVIVA 9G",
      "code_information": [
        {
          "code": "1495152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-TISSUE ATEC        TF-1",
      "code_information": [
        {
          "code": "1495228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-EVIVA STX   0913-12T",
      "code_information": [
        {
          "code": "1495304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE MULTICARE  MME-00347",
      "code_information": [
        {
          "code": "1495418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.3999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC",
      "code_information": [
        {
          "code": "2395902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC 50MM",
      "code_information": [
        {
          "code": "2395904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAT-SURGISAFE ABSORBANT FLOOR",
      "code_information": [
        {
          "code": "3000001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 323,
          "minimum": 67.83,
          "maximum": 236.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.5504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-FULL RADIUS 5.5MM",
      "code_information": [
        {
          "code": "3000006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.2358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO               2C4040",
      "code_information": [
        {
          "code": "3000090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CONFIDENCE 2839-99-002",
      "code_information": [
        {
          "code": "3000520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-HEMOSTASES  HC0001",
      "code_information": [
        {
          "code": "3000742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1597,
          "minimum": 335.37,
          "maximum": 1169.3234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 818.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-CLIP MED/LG 20 SMC",
      "code_information": [
        {
          "code": "3000753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 516.1278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP PK AM0004",
      "code_information": [
        {
          "code": "3000760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.6977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP    AM0005",
      "code_information": [
        {
          "code": "3000762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP  DISP   MCM20",
      "code_information": [
        {
          "code": "3000765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 518,
          "minimum": 108.78,
          "maximum": 379.2796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 265.4957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP LARGE MCL20",
      "code_information": [
        {
          "code": "3000766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 553,
          "minimum": 116.13,
          "maximum": 404.9066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 283.4346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP SM MCS20",
      "code_information": [
        {
          "code": "3000767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 569,
          "minimum": 119.49,
          "maximum": 416.6218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 291.6353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-AUTOMATIC 5MM AE05ML",
      "code_information": [
        {
          "code": "3000770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.7393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSISTANT-SUTURE 5MM     SW100",
      "code_information": [
        {
          "code": "3000865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1311,
          "minimum": 275.31,
          "maximum": 959.9142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 671.9399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-ANCHOR TISSUE ROBOTIC",
      "code_information": [
        {
          "code": "3001135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 332.6385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-ENDOPOUCH 10MM POUCH",
      "code_information": [
        {
          "code": "3001190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-DISPOSA 3MM       DBL-311",
      "code_information": [
        {
          "code": "3001371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IPRISM IPC05",
      "code_information": [
        {
          "code": "3001669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAR-TIBIAL LOCKING      141205",
      "code_information": [
        {
          "code": "3002092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1493,
          "minimum": 313.53,
          "maximum": 1093.1746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 765.2222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 1.9X120 390-201",
      "code_information": [
        {
          "code": "3002152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1576,
          "minimum": 330.96,
          "maximum": 1153.9472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 807.763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOFILTER-ASP FLTR",
      "code_information": [
        {
          "code": "3002210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 508,
          "minimum": 106.68,
          "maximum": 371.9576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.3703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CEMENT-COMPACT VACUUM",
      "code_information": [
        {
          "code": "3002214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 669.3772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           315.48",
      "code_information": [
        {
          "code": "3002244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.2      310.65",
      "code_information": [
        {
          "code": "3002246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MINI DRILL AT2M-1813",
      "code_information": [
        {
          "code": "3002257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1114.7745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145   03.010.104",
      "code_information": [
        {
          "code": "3002260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1668,
          "minimum": 350.28,
          "maximum": 1221.3096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 854.9167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    351.27",
      "code_information": [
        {
          "code": "3002270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3542,
          "minimum": 743.82,
          "maximum": 2593.4524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1815.4167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM      03.010.036",
      "code_information": [
        {
          "code": "3002274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3373,
          "minimum": 708.33,
          "maximum": 2469.7106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1728.7974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.060",
      "code_information": [
        {
          "code": "3002289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2190,
          "minimum": 459.9,
          "maximum": 1603.518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1122.4626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5           310.23",
      "code_information": [
        {
          "code": "3002291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 937,
          "minimum": 196.77,
          "maximum": 686.0714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 480.25,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM         310.19",
      "code_information": [
        {
          "code": "3002294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 949,
          "minimum": 199.29,
          "maximum": 694.8578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 486.4005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MMX150MM  511.417",
      "code_information": [
        {
          "code": "3002302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1642,
          "minimum": 344.82,
          "maximum": 1202.2724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 841.5907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2 ALL 1806-4200s",
      "code_information": [
        {
          "code": "3002305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1134,
          "minimum": 238.14,
          "maximum": 830.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 581.2204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X180MM 1806-4270S",
      "code_information": [
        {
          "code": "3002306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 623.2486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR        5091-206",
      "code_information": [
        {
          "code": "3002318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.5363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR",
      "code_information": [
        {
          "code": "3002324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.4296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-STEP DRILL         357.403",
      "code_information": [
        {
          "code": "3002361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3578,
          "minimum": 751.38,
          "maximum": 2619.8116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1833.8681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.4     310.530",
      "code_information": [
        {
          "code": "3002365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1282,
          "minimum": 269.22,
          "maximum": 938.6804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 657.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           1806-5020S",
      "code_information": [
        {
          "code": "3002379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1219,
          "minimum": 255.99,
          "maximum": 892.5518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 624.7863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM        388.394",
      "code_information": [
        {
          "code": "3002383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         60-20385",
      "code_information": [
        {
          "code": "3002391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 564.8191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 03.113.024",
      "code_information": [
        {
          "code": "3002394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1440,
          "minimum": 302.4,
          "maximum": 1054.368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 738.0576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 03.113.023",
      "code_information": [
        {
          "code": "3002399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1440,
          "minimum": 302.4,
          "maximum": 1054.368,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 738.0576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM 703542",
      "code_information": [
        {
          "code": "3002400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 658.1014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3MM 703541",
      "code_information": [
        {
          "code": "3002402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1335,
          "minimum": 280.35,
          "maximum": 977.487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 684.2409,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5085-2-032",
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        {
          "code": "3002403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM 5085-2-040",
      "code_information": [
        {
          "code": "3002410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 1.7MM",
      "code_information": [
        {
          "code": "3002760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1755,
          "minimum": 368.55,
          "maximum": 1285.011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 899.5077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO        1806-5000S",
      "code_information": [
        {
          "code": "3002772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1103,
          "minimum": 231.63,
          "maximum": 807.6166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 565.3316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM     03.010.061",
      "code_information": [
        {
          "code": "3002776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2190,
          "minimum": 459.9,
          "maximum": 1603.518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1122.4626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM    03.010.101S",
      "code_information": [
        {
          "code": "3002777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1114.7745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.6x",
      "code_information": [
        {
          "code": "3002779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2769,
          "minimum": 581.49,
          "maximum": 2027.4618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1419.2233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL W/STOP ALL   324.15x",
      "code_information": [
        {
          "code": "3002780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2797,
          "minimum": 587.37,
          "maximum": 2047.9634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1433.5744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.68",
      "code_information": [
        {
          "code": "3002782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2977,
          "minimum": 625.17,
          "maximum": 2179.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1525.8316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 17MM    357.394",
      "code_information": [
        {
          "code": "3002785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4976,
          "minimum": 1044.96,
          "maximum": 3643.4272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2550.399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM         700347",
      "code_information": [
        {
          "code": "3002791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1337,
          "minimum": 280.77,
          "maximum": 978.9514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 685.266,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1MM         702742",
      "code_information": [
        {
          "code": "3002793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1019,
          "minimum": 213.99,
          "maximum": 746.1118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 522.2783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X110MM     310.35",
      "code_information": [
        {
          "code": "3002794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 921,
          "minimum": 193.41,
          "maximum": 674.3562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 472.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER MINI       376900",
      "code_information": [
        {
          "code": "3002835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 9-9.5MM 5400-031-xxx",
      "code_information": [
        {
          "code": "3002951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1113,
          "minimum": 233.73,
          "maximum": 814.9386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 570.457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EXT ELECTRODE    E1551-6",
      "code_information": [
        {
          "code": "3002959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-TURBINATE INF SB2000SA",
      "code_information": [
        {
          "code": "3002962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1139,
          "minimum": 239.19,
          "maximum": 833.9758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 583.7831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SERRATED STND SB4000SS",
      "code_information": [
        {
          "code": "3002963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 666.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MYRINGOTOMY SPEAR TIP",
      "code_information": [
        {
          "code": "3003112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RAD 40 DEGREE 18-84006HR",
      "code_information": [
        {
          "code": "3003122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1727,
          "minimum": 362.67,
          "maximum": 1264.5094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 885.1566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RADNOID 18-84008",
      "code_information": [
        {
          "code": "3003123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1721,
          "minimum": 361.41,
          "maximum": 1260.1162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 882.0813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RASP SAW       510037113",
      "code_information": [
        {
          "code": "3003127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 567.8943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW MICR 9MM 2296-3-100s",
      "code_information": [
        {
          "code": "3003143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 267.0333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG SAW 9X25 ALL 2296s",
      "code_information": [
        {
          "code": "3003147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 267.0333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 5.5MMX18MM  KM 3-412",
      "code_information": [
        {
          "code": "3003150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW GIGLI ROUND  2808-01",
      "code_information": [
        {
          "code": "3003172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HEX COATED 2.75   E1450X",
      "code_information": [
        {
          "code": "3003200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-INF TURB 2.0  18-82040HR",
      "code_information": [
        {
          "code": "3003227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2469,
          "minimum": 518.49,
          "maximum": 1807.8018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1265.4613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD DISP   8000-140",
      "code_information": [
        {
          "code": "3003251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 117.3717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90Xxx    05.003.1xxS",
      "code_information": [
        {
          "code": "3003256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 319.825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380HR",
      "code_information": [
        {
          "code": "3003258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1739,
          "minimum": 365.19,
          "maximum": 1273.2958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 891.3071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380EM",
      "code_information": [
        {
          "code": "3003259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1633.9775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS     519.xxxS",
      "code_information": [
        {
          "code": "3003292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 397.731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CELL SAVER HI SP   CSP26x",
      "code_information": [
        {
          "code": "3003419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 777,
          "minimum": 163.17,
          "maximum": 568.9194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 398.2436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-SMARTMIX CTS    540176501",
      "code_information": [
        {
          "code": "3003433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-INTERNAL AR-1678-CP",
      "code_information": [
        {
          "code": "3003471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5500,
          "minimum": 1155,
          "maximum": 4027.1,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2818.97,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-UNIV X-ACT 11-2151-9",
      "code_information": [
        {
          "code": "3003472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 998,
          "minimum": 209.58,
          "maximum": 730.7356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 511.5149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-COLON CYTO        000110",
      "code_information": [
        {
          "code": "3003503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.5189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-WHISTLE CLEANING  000101",
      "code_information": [
        {
          "code": "3003605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT RND 2296-100-421",
      "code_information": [
        {
          "code": "3003756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL CUTTING 5300-010-901",
      "code_information": [
        {
          "code": "3003762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.4861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND          277-10-423",
      "code_information": [
        {
          "code": "3003782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND CUT 2.4MM  5091-225",
      "code_information": [
        {
          "code": "3003786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 124.0347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT 1.6   277-10-xxx",
      "code_information": [
        {
          "code": "3003792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-WATERMELON      1607-2-35",
      "code_information": [
        {
          "code": "3003805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 319.825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL   SP-7810",
      "code_information": [
        {
          "code": "3003812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 652.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 2MM 5820-013-0xx",
      "code_information": [
        {
          "code": "3003829",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 654.5136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND S03.000.009S",
      "code_information": [
        {
          "code": "3003841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND 4.0MM    277-10-240",
      "code_information": [
        {
          "code": "3003855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 161.4501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 5MM     5820-013-050",
      "code_information": [
        {
          "code": "3003856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING BLUE   FL-601-97B",
      "code_information": [
        {
          "code": "3003905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT STERILE MAS PLIF",
      "code_information": [
        {
          "code": "3003914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1462.2766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ARCH 6.5  80320",
      "code_information": [
        {
          "code": "3004042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 185.0269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO DBL 5MM PAL-505LL",
      "code_information": [
        {
          "code": "3004047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY PREMATURE",
      "code_information": [
        {
          "code": "3004048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.4437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY NEONATAL",
      "code_information": [
        {
          "code": "3004049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.4437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERPAY INFANT",
      "code_information": [
        {
          "code": "3004051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.4437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-308LS",
      "code_information": [
        {
          "code": "3004052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 379.2796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CURVED 100MM 20G 10.0M",
      "code_information": [
        {
          "code": "3004190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX FEM TFA-022-25",
      "code_information": [
        {
          "code": "3004225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 312.1369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX       TFA02025",
      "code_information": [
        {
          "code": "3004226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 312.1369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 27FR 96370-027",
      "code_information": [
        {
          "code": "3004235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1777,
          "minimum": 373.17,
          "maximum": 1301.1194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 910.7836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-I-STAT CREATININE",
      "code_information": [
        {
          "code": "3004750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 22FR 30CC      266722",
      "code_information": [
        {
          "code": "3004837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.8276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-5FR RAD PIGTAIL 5RPS110-N",
      "code_information": [
        {
          "code": "3004842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 364,
          "minimum": 76.44,
          "maximum": 266.5208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.5646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TACKER DELIVERY OMS-TTS",
      "code_information": [
        {
          "code": "3005077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3218,
          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1649.3537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHLOANGIOGRAM   20018-010",
      "code_information": [
        {
          "code": "3005234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 613,
          "minimum": 128.73,
          "maximum": 448.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 314.187,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 24Fr 5CC 265724",
      "code_information": [
        {
          "code": "3005414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.3151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3WAY         73022L",
      "code_information": [
        {
          "code": "3005435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 34FR-46FR ALL",
      "code_information": [
        {
          "code": "3007230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 312.6494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 36FR-46FR  TF36460",
      "code_information": [
        {
          "code": "3007235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 312.6494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP         AA01",
      "code_information": [
        {
          "code": "3007600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-ACU-DISPO      DCFT2",
      "code_information": [
        {
          "code": "3007601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP,MULTI-PIN LG 390.004",
      "code_information": [
        {
          "code": "3008494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4727,
          "minimum": 992.67,
          "maximum": 3461.1094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2422.7766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-NV DSC & IN-LINE ACTIVATO",
      "code_information": [
        {
          "code": "3008690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LAPRA-TY ABS SUTURE XC200",
      "code_information": [
        {
          "code": "3008699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 777,
          "minimum": 163.17,
          "maximum": 568.9194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 398.2436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIPS-HEM-O-LOC         544230",
      "code_information": [
        {
          "code": "3008728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.1788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK XL       544250",
      "code_information": [
        {
          "code": "3008731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X3/8 XA6062",
      "code_information": [
        {
          "code": "3009659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 871,
          "minimum": 182.91,
          "maximum": 637.7462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 446.4223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR ACCU-FLO 82-1504",
      "code_information": [
        {
          "code": "3009774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 580.7078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONSTAVAC-CBC II    225-28-614",
      "code_information": [
        {
          "code": "3009792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1463,
          "minimum": 307.23,
          "maximum": 1071.2086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 749.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR BOVIE DISP 301538",
      "code_information": [
        {
          "code": "3009842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR HIGH   26176LD/10",
      "code_information": [
        {
          "code": "3009843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNULATED",
      "code_information": [
        {
          "code": "3009845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1933,
          "minimum": 405.93,
          "maximum": 1415.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 990.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNUL 3.8MM",
      "code_information": [
        {
          "code": "3009850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 922.0595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-SILICONE RETRACTOR",
      "code_information": [
        {
          "code": "3009851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-DISPOSABLE ACTIVE DAC",
      "code_information": [
        {
          "code": "3009853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 146.0739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-8 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.2353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 146.0739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.3639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-30 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 190.6649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 428,
          "minimum": 89.88,
          "maximum": 313.3816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 219.3671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 240.3813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CORONARY PERF    30055",
      "code_information": [
        {
          "code": "3010039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MERCEDES     PAL-506LL",
      "code_information": [
        {
          "code": "3010053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS ALL SZS   681xx",
      "code_information": [
        {
          "code": "3010076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 551,
          "minimum": 115.71,
          "maximum": 403.4422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 282.4095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT ALL SZ",
      "code_information": [
        {
          "code": "3010079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL 1X4  2111-04-077",
      "code_information": [
        {
          "code": "3010088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2712,
          "minimum": 569.52,
          "maximum": 1985.7264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1390.0085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL ALL  2111-08-07x",
      "code_information": [
        {
          "code": "3010090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5695,
          "minimum": 1195.95,
          "maximum": 4169.879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2918.9153,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X20 657320",
      "code_information": [
        {
          "code": "3010104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 698.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X40 657340",
      "code_information": [
        {
          "code": "3010107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 698.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DUBIN              8390",
      "code_information": [
        {
          "code": "3010215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION         BID30",
      "code_information": [
        {
          "code": "3010259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 890,
          "minimum": 186.9,
          "maximum": 651.658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 456.1606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE LITE 30-403LITE",
      "code_information": [
        {
          "code": "3010311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3419,
          "minimum": 717.99,
          "maximum": 2503.3918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1752.3743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LAPARSCOP PLUME FILTER",
      "code_information": [
        {
          "code": "3010330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 101.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VAGINAL POSITIONING",
      "code_information": [
        {
          "code": "3010598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2367,
          "minimum": 497.07,
          "maximum": 1733.1174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1213.1822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-BLUNT TIP 5 PK BTD05",
      "code_information": [
        {
          "code": "3010867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1 5901-1126",
      "code_information": [
        {
          "code": "3011002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHAN W/TROCAR ALL SIZES",
      "code_information": [
        {
          "code": "3011730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 199,
          "minimum": 41.79,
          "maximum": 145.7078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 101.9955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT HUBLESS ALL SZS",
      "code_information": [
        {
          "code": "3011780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.9781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-MINI CHEST 500     16400",
      "code_information": [
        {
          "code": "3011787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1139,
          "minimum": 239.19,
          "maximum": 833.9758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 583.7831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FECAL MANAGEMENT 418000",
      "code_information": [
        {
          "code": "3011910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1469,
          "minimum": 308.49,
          "maximum": 1075.6018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 752.9213,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FECAL MANAGEMENT 411108",
      "code_information": [
        {
          "code": "3011911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.3151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-HIP W/POUCHES DYNJP8201",
      "code_information": [
        {
          "code": "3011920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.2212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BEACH CHAIR SHOULDER",
      "code_information": [
        {
          "code": "3011922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 257,
          "minimum": 53.97,
          "maximum": 188.1754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.7228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BARIATRIC      DYNJP3105",
      "code_information": [
        {
          "code": "3011926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 116.8591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-DOUBLE 44X66     ORS 320",
      "code_information": [
        {
          "code": "3011927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 250.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 12MM CD004",
      "code_information": [
        {
          "code": "3011949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE 3M SHORT   6661EZ",
      "code_information": [
        {
          "code": "3011953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-ISO IOBAN HIP       6617",
      "code_information": [
        {
          "code": "3011959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INTESTINAL 18X18.5 ISO1003",
      "code_information": [
        {
          "code": "3011960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 360,
          "minimum": 75.6,
          "maximum": 263.592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.5144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 10MM CD001",
      "code_information": [
        {
          "code": "3011961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI     326088-0000-000",
      "code_information": [
        {
          "code": "3011985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI FULL         306070",
      "code_information": [
        {
          "code": "3011987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 279,
          "minimum": 58.59,
          "maximum": 204.2838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.9987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER           ORS-400",
      "code_information": [
        {
          "code": "3011995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 302.9111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERI IRRIGATION    1016",
      "code_information": [
        {
          "code": "3012018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE HAND   DYNJP8005",
      "code_information": [
        {
          "code": "3012025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR GLASSCOCK  S-1000",
      "code_information": [
        {
          "code": "3012051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.3999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GENTLE CARE SURG 12-1",
      "code_information": [
        {
          "code": "3012060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 480,
          "minimum": 100.8,
          "maximum": 351.456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 246.0192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-TOPIFOAM      5710-30",
      "code_information": [
        {
          "code": "3012080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.2495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN TWIST 2.7MM W/AO F",
      "code_information": [
        {
          "code": "3012109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2077,
          "minimum": 436.17,
          "maximum": 1520.7794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1064.5456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.0MM ASNIS",
      "code_information": [
        {
          "code": "3012113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1913,
          "minimum": 401.73,
          "maximum": 1400.6986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 980.489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-HEX 1.1X67       15-1723",
      "code_information": [
        {
          "code": "3012115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1211,
          "minimum": 254.31,
          "maximum": 886.6942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 620.6859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3012118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN 4.0MM W/AO",
      "code_information": [
        {
          "code": "3012152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5392,
          "minimum": 1132.32,
          "maximum": 3948.0224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2763.6157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SHAFT-AO 2.6MMX122MM",
      "code_information": [
        {
          "code": "3012186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 749.3335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           310.48",
      "code_information": [
        {
          "code": "3012201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1176,
          "minimum": 246.96,
          "maximum": 861.0672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 602.747,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO SMALL  1320-3042S",
      "code_information": [
        {
          "code": "3012204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1181,
          "minimum": 248.01,
          "maximum": 864.7282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 605.3097,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1806-5010S",
      "code_information": [
        {
          "code": "3012206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1103,
          "minimum": 231.63,
          "maximum": 807.6166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 565.3316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 03.6MMX122MM",
      "code_information": [
        {
          "code": "3012207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1378,
          "minimum": 289.38,
          "maximum": 1008.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 706.2801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM       60-19326",
      "code_information": [
        {
          "code": "3012208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 569.9445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 13.0MM CANNULATED",
      "code_information": [
        {
          "code": "3012314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4464,
          "minimum": 937.44,
          "maximum": 3268.5408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2287.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0           310.21",
      "code_information": [
        {
          "code": "3012318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 498.1889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         MS-DCR20",
      "code_information": [
        {
          "code": "3012321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 LG 120MM",
      "code_information": [
        {
          "code": "3012325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1725,
          "minimum": 362.25,
          "maximum": 1263.045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 884.1315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 315.28",
      "code_information": [
        {
          "code": "3012330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1374,
          "minimum": 288.54,
          "maximum": 1006.0428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 704.23,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          310.288",
      "code_information": [
        {
          "code": "3012331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2           405883",
      "code_information": [
        {
          "code": "3012341",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1098,
          "minimum": 230.58,
          "maximum": 803.9556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.7689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X40   2274-12-000",
      "code_information": [
        {
          "code": "3012344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1940,
          "minimum": 407.4,
          "maximum": 1420.468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 994.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5          MS-DC35",
      "code_information": [
        {
          "code": "3012346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1055,
          "minimum": 221.55,
          "maximum": 772.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 540.7297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.201",
      "code_information": [
        {
          "code": "3012355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 912,
          "minimum": 191.52,
          "maximum": 667.7664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 467.4365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL               310.28",
      "code_information": [
        {
          "code": "3012356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 498.1889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.431",
      "code_information": [
        {
          "code": "3012357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1411,
          "minimum": 296.31,
          "maximum": 1033.1342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 723.1939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL            32-486265",
      "code_information": [
        {
          "code": "3012365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 769,
          "minimum": 161.49,
          "maximum": 563.0618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 394.1433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL         5820-107-530",
      "code_information": [
        {
          "code": "3012374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           AT2M-L1813",
      "code_information": [
        {
          "code": "3012378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2410,
          "minimum": 506.1,
          "maximum": 1764.602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1235.2214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED   310.634",
      "code_information": [
        {
          "code": "3012380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1370.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 5.0MM",
      "code_information": [
        {
          "code": "3012381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1370.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM 60-19340",
      "code_information": [
        {
          "code": "3012401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 564.8191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHRT 3.2 03.010.103S",
      "code_information": [
        {
          "code": "3012406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1666,
          "minimum": 349.86,
          "maximum": 1219.8452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 853.8916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL 5MM     DBL-511",
      "code_information": [
        {
          "code": "3012461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL LOOP      B0512",
      "code_information": [
        {
          "code": "3012465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 190.6649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X2.75 E1455",
      "code_information": [
        {
          "code": "3012472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X4  E1455-4",
      "code_information": [
        {
          "code": "3012473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-208",
      "code_information": [
        {
          "code": "3012474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1372,
          "minimum": 288.12,
          "maximum": 1004.5784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 703.2049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EZ CLEAN CAUTERY TIP",
      "code_information": [
        {
          "code": "3012505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.6772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE MOD     0014AM",
      "code_information": [
        {
          "code": "3012507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.9781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK  E2773-45",
      "code_information": [
        {
          "code": "3012520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 213.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MRI CONDITIONAL DISP",
      "code_information": [
        {
          "code": "3012521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LIGASURE      LS1037",
      "code_information": [
        {
          "code": "3012535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2512,
          "minimum": 527.52,
          "maximum": 1839.2864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1287.5005,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 2CHAN 8227410",
      "code_information": [
        {
          "code": "3012585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1545,
          "minimum": 324.45,
          "maximum": 1131.249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 791.8743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDISPEC        SE-1",
      "code_information": [
        {
          "code": "3012590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 281.3845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-RADIUS LOOP    R1010",
      "code_information": [
        {
          "code": "3012596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 190.6649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 6.5\\\" 0014M",
      "code_information": [
        {
          "code": "3012611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.4405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-TEFLON 6 1/2 BLADE",
      "code_information": [
        {
          "code": "3012613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDCAP-ROUND X-CORE    5960200",
      "code_information": [
        {
          "code": "3012635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4702,
          "minimum": 987.42,
          "maximum": 3442.8044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2409.9631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3012680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2877,
          "minimum": 604.17,
          "maximum": 2106.5394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1474.5776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVACUATOR-UROVAC       730-125",
      "code_information": [
        {
          "code": "3012699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVAC-SAF-T-VAC         ST9000S",
      "code_information": [
        {
          "code": "3012723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-GLUE             540133500",
      "code_information": [
        {
          "code": "3012805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXCISOR-BIOPSY CONE",
      "code_information": [
        {
          "code": "3012815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-DIALYSIS CATH  415612",
      "code_information": [
        {
          "code": "3012854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1265,
          "minimum": 265.65,
          "maximum": 926.233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 648.3631,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTRACTOR-TRIGEN DISP 71631320",
      "code_information": [
        {
          "code": "3012895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 669.3772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBE-VIPERSLIDE VPR-SLD2",
      "code_information": [
        {
          "code": "3012925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 1X6        007976",
      "code_information": [
        {
          "code": "3012991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 497.6763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 4\\\"X4\\\"       007836",
      "code_information": [
        {
          "code": "3012993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2074,
          "minimum": 435.54,
          "maximum": 1518.5828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1063.008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 200M",
      "code_information": [
        {
          "code": "3013060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2420,
          "minimum": 508.2,
          "maximum": 1771.924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1240.3468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 365M",
      "code_information": [
        {
          "code": "3013061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2010,
          "minimum": 422.1,
          "maximum": 1471.722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1030.2054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 550M",
      "code_information": [
        {
          "code": "3013062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2649,
          "minimum": 556.29,
          "maximum": 1939.5978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1357.7185,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 1000M",
      "code_information": [
        {
          "code": "3013063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3743,
          "minimum": 786.03,
          "maximum": 2740.6246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1918.4372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-COUDE HEYMAN   021300",
      "code_information": [
        {
          "code": "3013087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1917,
          "minimum": 402.57,
          "maximum": 1403.6274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 982.5392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-HEYMAN         021100",
      "code_information": [
        {
          "code": "3013090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1718,
          "minimum": 360.78,
          "maximum": 1257.9196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 880.5437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPER-          AR-7237-7",
      "code_information": [
        {
          "code": "3013107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 3  AR-7227-01",
      "code_information": [
        {
          "code": "3013134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 168.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 4  AR-7230-01",
      "code_information": [
        {
          "code": "3013135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 185.0269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-HEPA BACTERIA 00182",
      "code_information": [
        {
          "code": "3013160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.9781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PED OXYKID W/7' TUBING",
      "code_information": [
        {
          "code": "3013161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-INSUFFLATION BULB",
      "code_information": [
        {
          "code": "3013164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP     1599-05",
      "code_information": [
        {
          "code": "3013203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 237,
          "minimum": 49.77,
          "maximum": 173.5314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-PIRANHA 3FR     505-160",
      "code_information": [
        {
          "code": "3013317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2055,
          "minimum": 431.55,
          "maximum": 1504.671,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1053.2697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW      000300s",
      "code_information": [
        {
          "code": "3013320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RJ4 LC BIOPSY 160CM",
      "code_information": [
        {
          "code": "3013323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GEL-PROLARYN          8602M0K5",
      "code_information": [
        {
          "code": "3013462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4034,
          "minimum": 847.14,
          "maximum": 2953.6948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2067.5864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3014234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 514.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 6.5 DRILL",
      "code_information": [
        {
          "code": "3014235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 668.8647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-AR-8737-01",
      "code_information": [
        {
          "code": "3014239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3014272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.9312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-DBX MIX 2.5CC     058025",
      "code_information": [
        {
          "code": "3014900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2432,
          "minimum": 510.72,
          "maximum": 1780.7104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1246.4973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-WIRE .035      WS-0906ST",
      "code_information": [
        {
          "code": "3016121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.4328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2MM           292.65",
      "code_information": [
        {
          "code": "3016129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 552,
          "minimum": 115.92,
          "maximum": 404.1744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 282.9221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0MM 702460",
      "code_information": [
        {
          "code": "3016131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K SMOOTH TIP AGK16100",
      "code_information": [
        {
          "code": "3016134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-3.2       03.010.115",
      "code_information": [
        {
          "code": "3016135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1091,
          "minimum": 229.11,
          "maximum": 798.8302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 559.1811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K W/OLIVE STOP",
      "code_information": [
        {
          "code": "3016136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 722.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-SUT GABBY-FRATER SUT 013",
      "code_information": [
        {
          "code": "3016153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDETHREAD 150MM  292.72",
      "code_information": [
        {
          "code": "3016158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 461,
          "minimum": 96.81,
          "maximum": 337.5442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 236.2809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP AR894301",
      "code_information": [
        {
          "code": "3016164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.2495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-HALTER DISP 08143101",
      "code_information": [
        {
          "code": "3016272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 118,
          "minimum": 24.78,
          "maximum": 86.3996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 60.4797,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ADHESIVE 4\\\" WHITE",
      "code_information": [
        {
          "code": "3016326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1963",
      "code_information": [
        {
          "code": "3016347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1292,
          "minimum": 271.32,
          "maximum": 946.0024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 662.2017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOVAC-400ML LG   2550-004-10",
      "code_information": [
        {
          "code": "3016381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.5832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-HYDRODEB     1914001",
      "code_information": [
        {
          "code": "3016387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2186,
          "minimum": 459.06,
          "maximum": 1600.5892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1120.4124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM SNGL PK 33508G",
      "code_information": [
        {
          "code": "3016420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.4328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM DOUBLE  3384-4",
      "code_information": [
        {
          "code": "3016425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 434,
          "minimum": 91.14,
          "maximum": 317.7748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 222.4424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 2X4 2082",
      "code_information": [
        {
          "code": "3016450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 497.6763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 4X4 2083",
      "code_information": [
        {
          "code": "3016451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1255,
          "minimum": 263.55,
          "maximum": 918.911,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 643.2377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-J CAUTERY     60-5272-232",
      "code_information": [
        {
          "code": "3016500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-ULTRASLING III XLG",
      "code_information": [
        {
          "code": "3017486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 221.4173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUTTLE-ACCU PASS SUTURE 70DEG",
      "code_information": [
        {
          "code": "3019705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1334,
          "minimum": 280.14,
          "maximum": 976.7548,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 683.7284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-EVERGRIP LF  EVERGRIP61",
      "code_information": [
        {
          "code": "3019748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.0379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FDG",
      "code_information": [
        {
          "code": "3019810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2674,
          "minimum": 561.54,
          "maximum": 1957.9028,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1370.532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGL",
      "code_information": [
        {
          "code": "3019813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2674,
          "minimum": 561.54,
          "maximum": 1957.9028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1370.532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGD",
      "code_information": [
        {
          "code": "3019815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3010,
          "minimum": 632.1,
          "maximum": 2203.922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1542.7454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-PEELAWAY 16F",
      "code_information": [
        {
          "code": "3019878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 615,
          "minimum": 129.15,
          "maximum": 450.303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 315.2121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT 9FR 3 1/2 PI93",
      "code_information": [
        {
          "code": "3019879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 381,
          "minimum": 80.01,
          "maximum": 278.9682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.2777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP NICU HNICU37",
      "code_information": [
        {
          "code": "3019903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2MM 500373",
      "code_information": [
        {
          "code": "3020202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 709,
          "minimum": 148.89,
          "maximum": 519.1298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 363.3909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPER DISTRACTOR FF904SB",
      "code_information": [
        {
          "code": "3020203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1060,
          "minimum": 222.6,
          "maximum": 776.132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 543.2924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 17L 96550",
      "code_information": [
        {
          "code": "3020800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 515,
          "minimum": 108.15,
          "maximum": 377.083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 263.9581,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-I RING PUPIL 587000",
      "code_information": [
        {
          "code": "3020804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1251,
          "minimum": 262.71,
          "maximum": 915.9822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 641.1875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL VISULIZATION",
      "code_information": [
        {
          "code": "3020806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUG 03.804.522S",
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        {
          "code": "3020807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 859,
          "minimum": 180.39,
          "maximum": 628.9598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 440.2719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SCOPE WARMER TM500",
      "code_information": [
        {
          "code": "3020808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENTI SCAN IV DISP 177-092",
      "code_information": [
        {
          "code": "3020810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 451,
          "minimum": 94.71,
          "maximum": 330.2222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 231.1555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESSORY 700     72401850",
      "code_information": [
        {
          "code": "3020811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5472,
          "minimum": 1149.12,
          "maximum": 4006.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2804.6189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COAG  CSP208",
      "code_information": [
        {
          "code": "3020850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DILATOR NVM5       2029950",
      "code_information": [
        {
          "code": "3020915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2457.6293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-19",
      "code_information": [
        {
          "code": "3020920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 698.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-21",
      "code_information": [
        {
          "code": "3020922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2245,
          "minimum": 471.45,
          "maximum": 1643.789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1150.6523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC     96530-017",
      "code_information": [
        {
          "code": "3020928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 603.2596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IV MAXCESS         3240060",
      "code_information": [
        {
          "code": "3020969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8227,
          "minimum": 1727.67,
          "maximum": 6023.8094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4216.6666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX PT STARTER  50-0071",
      "code_information": [
        {
          "code": "3021029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1173.2041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHUNT NONINVASIVE  9733605",
      "code_information": [
        {
          "code": "3021032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3599,
          "minimum": 755.79,
          "maximum": 2635.1878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1844.6315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 4ML 1501262",
      "code_information": [
        {
          "code": "3021034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 825.1894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH&BOOT 3550-80",
      "code_information": [
        {
          "code": "3021046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 476,
          "minimum": 99.96,
          "maximum": 348.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 243.969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERITONEAL DIALYSIS 278006",
      "code_information": [
        {
          "code": "3021065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 589.421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHOULDER CANNULA 5CM  9718",
      "code_information": [
        {
          "code": "3021080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.6694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-URO MAX HI PRESURE 225-136",
      "code_information": [
        {
          "code": "3021090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1753,
          "minimum": 368.13,
          "maximum": 1283.5466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 898.4826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXTRACTION GTG14",
      "code_information": [
        {
          "code": "3021113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4570,
          "minimum": 959.7,
          "maximum": 3346.154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2342.3078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X12MM 663812",
      "code_information": [
        {
          "code": "3021130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 951,
          "minimum": 199.71,
          "maximum": 696.3222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 487.4255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CRESCENT         74-1010",
      "code_information": [
        {
          "code": "3021150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.0173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE,SLIT 2.4MM 45 DEGREE",
      "code_information": [
        {
          "code": "3021161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 134.798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-GRAFT ACL 10MM    232110",
      "code_information": [
        {
          "code": "3021173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2004,
          "minimum": 420.84,
          "maximum": 1467.3288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1027.1302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT CLEAR CUT 2.4",
      "code_information": [
        {
          "code": "3021199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 250.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDE PORT 1.1    78-2010",
      "code_information": [
        {
          "code": "3021203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-TUIP             880-217",
      "code_information": [
        {
          "code": "3021220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 749,
          "minimum": 157.29,
          "maximum": 548.4178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 383.8925,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE ALL AR-4000Ss",
      "code_information": [
        {
          "code": "3021225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE         AR-4068's",
      "code_information": [
        {
          "code": "3021227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 749.3335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDEPORT SAFETY 1.0MM",
      "code_information": [
        {
          "code": "3021241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINER-SZ25/36MM RL 12-105995",
      "code_information": [
        {
          "code": "3021635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4400,
          "minimum": 924,
          "maximum": 3221.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2255.176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-IMPACT         LF4318",
      "code_information": [
        {
          "code": "3021733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2708,
          "minimum": 568.68,
          "maximum": 1982.7976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1387.9583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-DRAINAGE LOCKABLE 50-7245",
      "code_information": [
        {
          "code": "3021737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 133.7729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 26FR      880-214",
      "code_information": [
        {
          "code": "3021821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 355.7028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-DISPOSA ALL",
      "code_information": [
        {
          "code": "3021826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-ELECTRODE 24FR   WA22037C",
      "code_information": [
        {
          "code": "3021880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1483,
          "minimum": 311.43,
          "maximum": 1085.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 760.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WIRE SNARE 8-14515",
      "code_information": [
        {
          "code": "3021881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 300.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-MS SSEP NEEDLE  8050315",
      "code_information": [
        {
          "code": "3022945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5246,
          "minimum": 1101.66,
          "maximum": 3841.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2688.7848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE MEP/EMG",
      "code_information": [
        {
          "code": "3022955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2602.1656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SINGLE PORT PAL 240LS",
      "code_information": [
        {
          "code": "3023177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 407.9818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY STEALTH  9733068",
      "code_information": [
        {
          "code": "3027284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4784,
          "minimum": 1004.64,
          "maximum": 3502.8448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2451.9914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY TRU CUT 2N2700s",
      "code_information": [
        {
          "code": "3027285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 108.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY CUT      4418-16",
      "code_information": [
        {
          "code": "3027295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DEFLUX 23GX3.7FX350mm",
      "code_information": [
        {
          "code": "3027296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 744,
          "minimum": 156.24,
          "maximum": 544.7568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 381.3298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DISP INSUF      S100000",
      "code_information": [
        {
          "code": "3027310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 482,
          "minimum": 101.22,
          "maximum": 352.9204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 247.0443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ELECTRODE COATD E1465-6",
      "code_information": [
        {
          "code": "3027313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ENDOPATH INSUFF   PN120",
      "code_information": [
        {
          "code": "3027315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 719,
          "minimum": 150.99,
          "maximum": 526.4518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 368.5163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL       105-1314",
      "code_information": [
        {
          "code": "3027318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-20      G00013",
      "code_information": [
        {
          "code": "3027330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FORAMEN 20G      041829",
      "code_information": [
        {
          "code": "3027344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.7041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-6 DJ6011X",
      "code_information": [
        {
          "code": "3027346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 292,
          "minimum": 61.32,
          "maximum": 213.8024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 149.6617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR        1650050",
      "code_information": [
        {
          "code": "3027347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 390,
          "minimum": 81.9,
          "maximum": 285.558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 199.8906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSULATED EDGE   E1465B",
      "code_information": [
        {
          "code": "3027368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TR-CRON 2-0 STR W/10 SW",
      "code_information": [
        {
          "code": "3027402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 223.98,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR W/SHEATH",
      "code_information": [
        {
          "code": "3027403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 626,
          "minimum": 131.46,
          "maximum": 458.3572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 320.85,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OPUS SPEEDSTITCH",
      "code_information": [
        {
          "code": "3027425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 397,
          "minimum": 83.37,
          "maximum": 290.6834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 203.4784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OCTRODE 6\\\"         1116",
      "code_information": [
        {
          "code": "3027430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODESSECTION   N103A",
      "code_information": [
        {
          "code": "3027433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 690,
          "minimum": 144.9,
          "maximum": 505.218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 353.6526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION      AR-13991N",
      "code_information": [
        {
          "code": "3027443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 749.3335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SIDEKICK 21GA 14.6\\\"",
      "code_information": [
        {
          "code": "3027445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 793,
          "minimum": 166.53,
          "maximum": 580.6346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 406.4442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODISSECTION   E1xxx",
      "code_information": [
        {
          "code": "3027520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 795,
          "minimum": 166.95,
          "maximum": 582.099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 407.4693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-W/BASEPLATE BSDN-18-7.0",
      "code_information": [
        {
          "code": "3027587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 5MM  VS101005",
      "code_information": [
        {
          "code": "3027591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1299,
          "minimum": 272.79,
          "maximum": 951.1278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 665.7895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VERSASTEP 14GA VS150000",
      "code_information": [
        {
          "code": "3027593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 600,
          "minimum": 126,
          "maximum": 439.32,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 307.524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TROCAR 12MM VS101000s",
      "code_information": [
        {
          "code": "3027595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1224,
          "minimum": 257.04,
          "maximum": 896.2128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 627.349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-WILSON PENILE IMPLANT",
      "code_information": [
        {
          "code": "3029175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2504,
          "minimum": 525.84,
          "maximum": 1833.4288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1283.4002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FENWAL TRANSFER 4R2014",
      "code_information": [
        {
          "code": "3029199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAGNETIC DRAPE    31140562",
      "code_information": [
        {
          "code": "3029201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY ELITE VIAL     LC3001",
      "code_information": [
        {
          "code": "3029202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3536,
          "minimum": 742.56,
          "maximum": 2589.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1812.3414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SENSA TRAC M8275057/10",
      "code_information": [
        {
          "code": "3029214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-PERFUSION CUSTOM  CK0226R",
      "code_information": [
        {
          "code": "3029252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3994,
          "minimum": 838.74,
          "maximum": 2924.4068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2047.0848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SHOULDER ARTHROSCOP 29367",
      "code_information": [
        {
          "code": "3029266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 133.7729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SINUS KENNEDY      400422",
      "code_information": [
        {
          "code": "3029267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-TOTAL JOINT    DYNJ31778A",
      "code_information": [
        {
          "code": "3029268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 604.7972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM     440400",
      "code_information": [
        {
          "code": "3029278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VITRECTOMY CENTURION",
      "code_information": [
        {
          "code": "3029308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH  82-151x",
      "code_information": [
        {
          "code": "3029345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1307,
          "minimum": 274.47,
          "maximum": 956.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 669.8898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SMART STITCH PERFECT",
      "code_information": [
        {
          "code": "3029347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 917,
          "minimum": 192.57,
          "maximum": 671.4274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 469.9992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE           032401",
      "code_information": [
        {
          "code": "3029348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE LF 022701",
      "code_information": [
        {
          "code": "3029356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 713,
          "minimum": 149.73,
          "maximum": 522.0586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 365.441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-HEMA KNITTED   HGK75/75P",
      "code_information": [
        {
          "code": "3029426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1254,
          "minimum": 263.34,
          "maximum": 918.1788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.7252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-ACTIVA 2.5 INTELLIDOSE",
      "code_information": [
        {
          "code": "3029528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-DISPOSABLE  26-1221",
      "code_information": [
        {
          "code": "3029529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORIENTATION 2307-71-000",
      "code_information": [
        {
          "code": "3029762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 509.4648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-NAVIGATION 6007-003-150",
      "code_information": [
        {
          "code": "3029767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 479.2249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ARM ELEVATION 79-90500",
      "code_information": [
        {
          "code": "3029771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KNEE PROCEDURE TRACK 10712",
      "code_information": [
        {
          "code": "3029811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 698.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-DEMAYO LEG 110550",
      "code_information": [
        {
          "code": "3029813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.5755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BREAKAWAY GUIDE 2.5MM",
      "code_information": [
        {
          "code": "3029840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2605,
          "minimum": 547.05,
          "maximum": 1907.381,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1335.1667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144110",
      "code_information": [
        {
          "code": "3029841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1086,
          "minimum": 228.06,
          "maximum": 795.1692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 556.6184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DHS GUIDE          900.723",
      "code_information": [
        {
          "code": "3029855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 658,
          "minimum": 138.18,
          "maximum": 481.7876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 337.2513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-POSITIONING EZ CLIP 2MM",
      "code_information": [
        {
          "code": "3029858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 575.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-FLUTED HEADLESS 7650-2038A",
      "code_information": [
        {
          "code": "3029885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1881,
          "minimum": 395.01,
          "maximum": 1377.2682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 964.0877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE              357.399",
      "code_information": [
        {
          "code": "3029929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1109,
          "minimum": 232.89,
          "maximum": 812.0098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 568.4069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PINS-GUIDE 7.3         900.726",
      "code_information": [
        {
          "code": "3030050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 943,
          "minimum": 198.03,
          "maximum": 690.4646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 483.3252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z463G",
      "code_information": [
        {
          "code": "3032618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1\\\"",
      "code_information": [
        {
          "code": "3033301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 48,
          "minimum": 10.08,
          "maximum": 35.1456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 24.6019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 16FR 10ML",
      "code_information": [
        {
          "code": "3033303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F SCREWS 45-80040",
      "code_information": [
        {
          "code": "3033883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 749.3335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-LARGE SOFT       PCP40",
      "code_information": [
        {
          "code": "3033952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POINTER-TRACER         9733423",
      "code_information": [
        {
          "code": "3034140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3396,
          "minimum": 713.16,
          "maximum": 2486.5512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1740.5858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-BIOPSY             AUR-BP",
      "code_information": [
        {
          "code": "3034190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 316,
          "minimum": 66.36,
          "maximum": 231.3752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 161.9626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-GEL HAND            C8XX2",
      "code_information": [
        {
          "code": "3034194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2024.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOCATCH-II W/POUCH ALL 173's",
      "code_information": [
        {
          "code": "3034302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2140,
          "minimum": 449.4,
          "maximum": 1566.908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1096.8356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD ENTERAL 7FR 350CM",
      "code_information": [
        {
          "code": "3034510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NEUROVISION M5   2012021",
      "code_information": [
        {
          "code": "3034522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PIGTAIL 28-0174",
      "code_information": [
        {
          "code": "3034526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 545.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LAPAROSCOPIC 5MM  160655",
      "code_information": [
        {
          "code": "3034572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 589.9335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 2.3MM 6.9FR 300CM",
      "code_information": [
        {
          "code": "3034891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-WOUND GELPOINT CNGL2",
      "code_information": [
        {
          "code": "3038330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2168.5567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-PAIN ONQ 400ML    PM028-A",
      "code_information": [
        {
          "code": "3038635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1884,
          "minimum": 395.64,
          "maximum": 1379.4648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 965.6254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-KNOT 2-0 FIBERWIRE",
      "code_information": [
        {
          "code": "3038667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 668.8647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-DEKNATEL 4.4      MDP-44",
      "code_information": [
        {
          "code": "3038930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 398,
          "minimum": 83.58,
          "maximum": 291.4156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 203.9909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GREEN    ECR45G",
      "code_information": [
        {
          "code": "3039881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1406,
          "minimum": 295.26,
          "maximum": 1029.4732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 720.6312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO LINEAR       TR35B",
      "code_information": [
        {
          "code": "3039888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 838,
          "minimum": 175.98,
          "maximum": 613.5836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 429.5085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-TUBING         RF10210",
      "code_information": [
        {
          "code": "3039889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W564",
      "code_information": [
        {
          "code": "3039894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W332",
      "code_information": [
        {
          "code": "3039896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN        XR30G",
      "code_information": [
        {
          "code": "3039899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.9047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH       170056",
      "code_information": [
        {
          "code": "3039902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 441.8095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-VASCULAR/THIN     TR45W",
      "code_information": [
        {
          "code": "3039909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 623.2486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM              XR30B",
      "code_information": [
        {
          "code": "3039911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.9047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STANDARD BLUE     6R45B",
      "code_information": [
        {
          "code": "3039912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 623.2486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40B",
      "code_information": [
        {
          "code": "3039913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1699,
          "minimum": 356.79,
          "maximum": 1244.0078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 870.8055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD- STAPLE TCR-55",
      "code_information": [
        {
          "code": "3039914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 499,
          "minimum": 104.79,
          "maximum": 365.3678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.7575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-LINEAR CUTTER    TCR-75",
      "code_information": [
        {
          "code": "3039916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 820,
          "minimum": 172.2,
          "maximum": 600.404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 420.2828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40G",
      "code_information": [
        {
          "code": "3039917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1699,
          "minimum": 356.79,
          "maximum": 1244.0078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 870.8055,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER    TCT75",
      "code_information": [
        {
          "code": "3039918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1465,
          "minimum": 307.65,
          "maximum": 1072.673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 750.8711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM BLUE         XR60B",
      "code_information": [
        {
          "code": "3039920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 514,
          "minimum": 107.94,
          "maximum": 376.3508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 263.4456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO GIA 30/3.5  030452",
      "code_information": [
        {
          "code": "3039932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2061,
          "minimum": 432.81,
          "maximum": 1509.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1056.3449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-CARIOTOMY        205",
      "code_information": [
        {
          "code": "3039975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 465,
          "minimum": 97.65,
          "maximum": 340.473,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.3311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-DISP FILTRA 04259",
      "code_information": [
        {
          "code": "3039981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 299.8359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-OMMAYA    NL850-121x",
      "code_information": [
        {
          "code": "3040439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3043,
          "minimum": 639.03,
          "maximum": 2228.0846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1559.6592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD UNIV     050602",
      "code_information": [
        {
          "code": "3040461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 156.8372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-C-SECTION DISP G6314",
      "code_information": [
        {
          "code": "3040500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 422.333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND          C8404",
      "code_information": [
        {
          "code": "3040501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 422.333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEXOR TENDON",
      "code_information": [
        {
          "code": "3040509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1372.5821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-LONESTAR        3304",
      "code_information": [
        {
          "code": "3040511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1080,
          "minimum": 226.8,
          "maximum": 790.776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 553.5432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ORTHO ALEXIS   HR004",
      "code_information": [
        {
          "code": "3040513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1611,
          "minimum": 338.31,
          "maximum": 1179.5742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 825.7019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE        013593",
      "code_information": [
        {
          "code": "3040518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 117.18,
          "maximum": 408.5676,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 285.9973,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-SURGICAL RING   3715",
      "code_information": [
        {
          "code": "3040521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 287.7,
          "maximum": 1003.114,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 702.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-LOOPED 3 PRONG  5030",
      "code_information": [
        {
          "code": "3040525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND LG       C8303",
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        {
          "code": "3040527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND MEDIUM   C8302",
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        {
          "code": "3040530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XL       C8304",
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        {
          "code": "3040532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND SMALL    C8301",
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        {
          "code": "3040533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 220.3922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XSMALL   C8312",
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        {
          "code": "3040534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 220.3922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-MALYUGIN ALL SZS MAL-000x",
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        {
          "code": "3040661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "maximum": 1145.893,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 802.1251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.8 CANN DRI",
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        {
          "code": "3040704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-2.0X7          AR-7200S",
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        {
          "code": "3044850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 423.8706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 2.3 BIPOLAR",
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        {
          "code": "3044897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1427.4239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS MALLEABLE BI",
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        {
          "code": "3044899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 675.15,
          "maximum": 2354.023,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1647.8161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION ANSPACH 111613",
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        {
          "code": "3044922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 495.1136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCISSORS-ENDODUT METZ     3142",
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        {
          "code": "3044930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 96.6,
          "maximum": 336.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68HP ALL",
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        {
          "code": "3049715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 87.78,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY ALL 351-3000'sS",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRI PORT III PAL 303LS",
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        {
          "code": "3050004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 4.0X170 144170",
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        {
          "code": "3050009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 484.3503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CELLEBRITY CYTOLOGY",
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        {
          "code": "3050015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 49.14,
          "maximum": 171.3348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 119.9344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATIR SM DISP 13MM",
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        {
          "code": "3055843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 100.9704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 2ML 1506078",
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        {
          "code": "3055845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 314.79,
          "maximum": 1097.5678,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 768.2975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL ALL SZS 456.30Xs",
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        {
          "code": "3055898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 772.17,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MISTY NEB W/FILTER",
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        {
          "code": "3058511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 14.07,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "CUTTER-HELIOCOIDAL RASP 3.2MM",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 799.5624,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONE MILL DISP",
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        {
          "code": "3058513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 376.11,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-CORE IRRIGATION",
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        {
          "code": "3058514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 99.12,
          "maximum": 345.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 2.3MM",
      "code_information": [
        {
          "code": "3058515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1089,
          "minimum": 228.69,
          "maximum": 797.3658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 558.1561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-SOFT TOUCH RND FLUTED ALL",
      "code_information": [
        {
          "code": "3058516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND ALL SIZES",
      "code_information": [
        {
          "code": "3058517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 654.5136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND COURSE ALL",
      "code_information": [
        {
          "code": "3058518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 3.0MM",
      "code_information": [
        {
          "code": "3058521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1089,
          "minimum": 228.69,
          "maximum": 797.3658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 558.1561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CUTTING DIAMOND 25.4X0.8",
      "code_information": [
        {
          "code": "3058522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 534.0667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 310.23S",
      "code_information": [
        {
          "code": "3058526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1551,
          "minimum": 325.71,
          "maximum": 1135.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 794.9495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 02.7 CSS-072-27",
      "code_information": [
        {
          "code": "3058530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1347,
          "minimum": 282.87,
          "maximum": 986.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 690.3914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110 143110",
      "code_information": [
        {
          "code": "3058543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 683,
          "minimum": 143.43,
          "maximum": 500.0926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 350.0648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EPIDURAL 117\\\" INF 1633902",
      "code_information": [
        {
          "code": "3058611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.4437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE 10X5",
      "code_information": [
        {
          "code": "3058612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1239,
          "minimum": 260.19,
          "maximum": 907.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 635.0371,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-FLOW 50 COBLATION",
      "code_information": [
        {
          "code": "3058620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1833,
          "minimum": 384.93,
          "maximum": 1342.1226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 939.4858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STONCUTTER 5.5 7205331",
      "code_information": [
        {
          "code": "3058624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 956,
          "minimum": 200.76,
          "maximum": 699.9832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 489.9882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3058625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 ORBIT 7205323",
      "code_information": [
        {
          "code": "3058626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 326.488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4.0 1864G",
      "code_information": [
        {
          "code": "3058639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL FLEX MED 27MM",
      "code_information": [
        {
          "code": "3058643",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.3935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-RETRIEVAL 30MM DGN-538-5",
      "code_information": [
        {
          "code": "3058644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 941,
          "minimum": 197.61,
          "maximum": 689.0002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 482.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I KNIFE SURG 8065921552",
      "code_information": [
        {
          "code": "3058653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.7164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 2.0MM 5820-010-020",
      "code_information": [
        {
          "code": "3058655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1105,
          "minimum": 232.05,
          "maximum": 809.081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 566.3567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDO FEEDING 12FR X 60”",
      "code_information": [
        {
          "code": "3058693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 193.7401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MINI 4.0 283459",
      "code_information": [
        {
          "code": "3058696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1275,
          "minimum": 267.75,
          "maximum": 933.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 653.4885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 FULL RADIUS",
      "code_information": [
        {
          "code": "3058697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1275,
          "minimum": 267.75,
          "maximum": 933.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 653.4885,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3058698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 919,
          "minimum": 192.99,
          "maximum": 672.8918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 471.0243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 018 14MMX34CM",
      "code_information": [
        {
          "code": "3058707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2168.5567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-240",
      "code_information": [
        {
          "code": "3058716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANOSCOPE-BEVELED DISP 103X18M",
      "code_information": [
        {
          "code": "3058720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-EXPEL NEPHR I/E 8.3/22",
      "code_information": [
        {
          "code": "3058729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1262,
          "minimum": 265.02,
          "maximum": 924.0364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 646.8255,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH 15FR 71C",
      "code_information": [
        {
          "code": "3058737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.2038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-VPAD 2 INS-0050",
      "code_information": [
        {
          "code": "3058749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2207,
          "minimum": 463.47,
          "maximum": 1615.9654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1131.1758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-ALWAYS ON TIP INS-0352",
      "code_information": [
        {
          "code": "3058751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1495.5917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-19 GA ANSO INS-0382",
      "code_information": [
        {
          "code": "3058752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1495.5917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GA ANSO INS 0392",
      "code_information": [
        {
          "code": "3058753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1495.5917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GA NITINOL INS-5410",
      "code_information": [
        {
          "code": "3058754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4175,
          "minimum": 876.75,
          "maximum": 3056.935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2139.8545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPINPERC INS-5600",
      "code_information": [
        {
          "code": "3058755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2207,
          "minimum": 463.47,
          "maximum": 1615.9654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1131.1758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE DISTRACTOR DISP",
      "code_information": [
        {
          "code": "3058766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 289.0726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE 1.5X36",
      "code_information": [
        {
          "code": "3058775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 AR 8943-16",
      "code_information": [
        {
          "code": "3058786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1013,
          "minimum": 212.73,
          "maximum": 741.7186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 519.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPIN EWC BIOPSY GUIDE",
      "code_information": [
        {
          "code": "3058788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3127,
          "minimum": 656.67,
          "maximum": 2289.5894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1602.7126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DISP SHOULDER 1.8MM",
      "code_information": [
        {
          "code": "3058805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1659,
          "minimum": 348.39,
          "maximum": 1214.7198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 850.3039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENTRAINER-AIR RT008",
      "code_information": [
        {
          "code": "3058809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 5.0 5050",
      "code_information": [
        {
          "code": "3058819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58043,
          "minimum": 12189.03,
          "maximum": 42499.0846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29749.3592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 7.0 7050",
      "code_information": [
        {
          "code": "3058820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60044,
          "minimum": 12609.24,
          "maximum": 43964.2168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30774.9518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 BV-1 M8709",
      "code_information": [
        {
          "code": "3058836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 382.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 2MMXxxCM",
      "code_information": [
        {
          "code": "3058843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4220,
          "minimum": 886.2,
          "maximum": 3089.884,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2162.9188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX20CM",
      "code_information": [
        {
          "code": "3058844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5064,
          "minimum": 1063.44,
          "maximum": 3707.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2595.5026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX30CM",
      "code_information": [
        {
          "code": "3058845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5591,
          "minimum": 1174.11,
          "maximum": 4093.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2865.6111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 CX ALL",
      "code_information": [
        {
          "code": "3058846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2168.5567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HEATED AIRVO 900PT501",
      "code_information": [
        {
          "code": "3058860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO SM OPT942",
      "code_information": [
        {
          "code": "3058861",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.6006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO MED OPT944",
      "code_information": [
        {
          "code": "3058862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.6006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO LARGE OPT946",
      "code_information": [
        {
          "code": "3058863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.6006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-013-000 SZ4",
      "code_information": [
        {
          "code": "3058864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.4437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HEALING W/PLUG 30MM 95084",
      "code_information": [
        {
          "code": "3058868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.7086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN LITE FUD023",
      "code_information": [
        {
          "code": "3058869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.5MM",
      "code_information": [
        {
          "code": "3058875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CONTOUR CERVICAL 13-15",
      "code_information": [
        {
          "code": "3058876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-RIB UNIVERSAL 8” MALE",
      "code_information": [
        {
          "code": "3058877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3.0 1893G",
      "code_information": [
        {
          "code": "3058878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SLIM MED",
      "code_information": [
        {
          "code": "3058885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 119.4218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-SYSTEM UA2007",
      "code_information": [
        {
          "code": "3058887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 162,
          "minimum": 34.02,
          "maximum": 118.6164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.0315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WATER SUCTION BIOPSY VALVE",
      "code_information": [
        {
          "code": "3058903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-ACCUSTAT 125NM S 801015",
      "code_information": [
        {
          "code": "3058929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5081,
          "minimum": 1067.01,
          "maximum": 3720.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2604.2157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MIDLINE 5FR BIO FLO",
      "code_information": [
        {
          "code": "3058932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 1.4X27MM",
      "code_information": [
        {
          "code": "3058955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3358,
          "minimum": 705.18,
          "maximum": 2458.7276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1721.1093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON,CAPIOX HPH-1000",
      "code_information": [
        {
          "code": "3058981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 436.6841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOBLADE GASTRO",
      "code_information": [
        {
          "code": "3058983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2587.8145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORTHOLOCK 3X110MM EX",
      "code_information": [
        {
          "code": "3058990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 479.2249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X 343MM",
      "code_information": [
        {
          "code": "3058991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1159,
          "minimum": 243.39,
          "maximum": 848.6198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 594.0339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y935H",
      "code_information": [
        {
          "code": "3059006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.0X40X91MM",
      "code_information": [
        {
          "code": "3059015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.9914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-GENESYS HTA M006580211",
      "code_information": [
        {
          "code": "3059026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6769,
          "minimum": 1421.49,
          "maximum": 4956.2618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3469.3833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-CLEANING STICK 900PT602",
      "code_information": [
        {
          "code": "3059061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-QUADFUSE 9” EXT SMALLBORE",
      "code_information": [
        {
          "code": "3059062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.1067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED OPT316",
      "code_information": [
        {
          "code": "3059066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 522,
          "minimum": 109.62,
          "maximum": 382.2084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 267.5459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PED 900PT531",
      "code_information": [
        {
          "code": "3059068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 722,
          "minimum": 151.62,
          "maximum": 528.6484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 370.0539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-ABSOLUTE PSI-TEC",
      "code_information": [
        {
          "code": "3059124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.8012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-HEADREST SOFTOUCH",
      "code_information": [
        {
          "code": "3059127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ESOPHYX TIF R2007",
      "code_information": [
        {
          "code": "3059129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21712,
          "minimum": 4559.52,
          "maximum": 15897.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11128.2685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTER CONNECT PT-5558-F",
      "code_information": [
        {
          "code": "3059131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 3.5X195 700353",
      "code_information": [
        {
          "code": "3059137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1228,
          "minimum": 257.88,
          "maximum": 899.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 629.3991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACQUIRE EUS FND",
      "code_information": [
        {
          "code": "3059156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 2.0MM BIT",
      "code_information": [
        {
          "code": "3059170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2114,
          "minimum": 443.94,
          "maximum": 1547.8708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1083.5096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-IMPLANT SIZING SG - x",
      "code_information": [
        {
          "code": "3059171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIALYZER-HIGH FLUX 1.6 720DH16",
      "code_information": [
        {
          "code": "3059177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ULTRAPERC FULL 100/573/000",
      "code_information": [
        {
          "code": "3059178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1545,
          "minimum": 324.45,
          "maximum": 1131.249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 791.8743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT MED",
      "code_information": [
        {
          "code": "3059179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENVEO PRO LOADING",
      "code_information": [
        {
          "code": "3059185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2618,
          "minimum": 549.78,
          "maximum": 1916.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1341.8297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 1.5MM NEEDLES",
      "code_information": [
        {
          "code": "3059187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 460,
          "minimum": 96.6,
          "maximum": 336.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 235.7684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN 5X5CM FUD021",
      "code_information": [
        {
          "code": "3059209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-KNOTLESS S-TAK STEP 3MM",
      "code_information": [
        {
          "code": "3059213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW OSC SAGITTAL xxMM",
      "code_information": [
        {
          "code": "3059220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 319.825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO DURACLIP 235CM 11MM",
      "code_information": [
        {
          "code": "3059232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 722.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-HEEL PRESSURE MDT825",
      "code_information": [
        {
          "code": "3059240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.8655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT LG",
      "code_information": [
        {
          "code": "3059245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT SM",
      "code_information": [
        {
          "code": "3059246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-POLAR COMBO 1232PP",
      "code_information": [
        {
          "code": "3059252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 907,
          "minimum": 190.47,
          "maximum": 664.1054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.8738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-TRI STAPLE 2.0 SIG30AVM",
      "code_information": [
        {
          "code": "3059259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2871,
          "minimum": 602.91,
          "maximum": 2102.1462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1471.5023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND 1.0MM",
      "code_information": [
        {
          "code": "3059273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 654.5136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION LARGE",
      "code_information": [
        {
          "code": "3059275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION MED",
      "code_information": [
        {
          "code": "3059281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 279,
          "minimum": 58.59,
          "maximum": 204.2838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.9987,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 15\\\" ADJ ILIO",
      "code_information": [
        {
          "code": "3059288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 328,
          "minimum": 68.88,
          "maximum": 240.1616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 168.1131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP ALL",
      "code_information": [
        {
          "code": "3059603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT 111645",
      "code_information": [
        {
          "code": "3059922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 399.2687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X140 143140",
      "code_information": [
        {
          "code": "3059924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1195,
          "minimum": 250.95,
          "maximum": 874.979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 612.4853,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LIGASURE SM  LF1212A",
      "code_information": [
        {
          "code": "3059951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3010,
          "minimum": 632.1,
          "maximum": 2203.922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1542.7454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-LEVER EDGE    4100-01",
      "code_information": [
        {
          "code": "3059965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1454,
          "minimum": 305.34,
          "maximum": 1064.6188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 745.2332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ABC SINGLE FUNCTION",
      "code_information": [
        {
          "code": "3059973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 435.659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATCHER-STONE WITH TUB 840-750",
      "code_information": [
        {
          "code": "3059984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 825,
          "minimum": 173.25,
          "maximum": 604.065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 422.8455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP       7-382",
      "code_information": [
        {
          "code": "3059989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ISOLATOR  BIP   OSL2",
      "code_information": [
        {
          "code": "3059996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11959,
          "minimum": 2511.39,
          "maximum": 8756.3798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6129.4659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-LINEAR 60GRN      TX60G",
      "code_information": [
        {
          "code": "3060001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 913,
          "minimum": 191.73,
          "maximum": 668.4986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 467.949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM GREEN        XR60G",
      "code_information": [
        {
          "code": "3060002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 550,
          "minimum": 115.5,
          "maximum": 402.71,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 281.897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE   RC014MIBB",
      "code_information": [
        {
          "code": "3060082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 479.2249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CORONARY PERFUSN 10004",
      "code_information": [
        {
          "code": "3060083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEX IRIS     611.75",
      "code_information": [
        {
          "code": "3060129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 858,
          "minimum": 180.18,
          "maximum": 628.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 439.7593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 8\\\"  7708-000-10",
      "code_information": [
        {
          "code": "3060132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 161.4501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VESSEL           30003",
      "code_information": [
        {
          "code": "3060134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 101,
          "minimum": 21.21,
          "maximum": 73.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SWANSON SUTURE  11-0675",
      "code_information": [
        {
          "code": "3060151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 508.4397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-T-TUBE 16FR       0099830",
      "code_information": [
        {
          "code": "3060199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-RETRACTO 12\\\" 1041",
      "code_information": [
        {
          "code": "3060247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE MEDIUM   9893",
      "code_information": [
        {
          "code": "3060289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.2449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH      SZ5  A0A04",
      "code_information": [
        {
          "code": "3060306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 133.7729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-UNIV     60-6010-001",
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        {
          "code": "3060315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERZ-REFLECTIVE PK   PM 8005",
      "code_information": [
        {
          "code": "3060317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-SPRING CLIP 6MM  CSOFT6",
      "code_information": [
        {
          "code": "3060318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.2353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-SILVERSTEIN PK 1428010",
      "code_information": [
        {
          "code": "3060385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.1209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0 CT-2 Z332H",
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        {
          "code": "3060417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROGRAMMER-TEST STIM 3531",
      "code_information": [
        {
          "code": "3060442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2604,
          "minimum": 546.84,
          "maximum": 1906.6488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1334.6542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MINI HOOK 357501",
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        {
          "code": "3060443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 4.0MM 03.000.012S",
      "code_information": [
        {
          "code": "3060451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 745,
          "minimum": 156.45,
          "maximum": 545.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 381.8423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 5.0MM 03.000.015S",
      "code_information": [
        {
          "code": "3060452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90X9.5 05.003.126S",
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        {
          "code": "3060455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 319.825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 10M",
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        {
          "code": "3060460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3512,
          "minimum": 737.52,
          "maximum": 2571.4864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1800.0405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT",
      "code_information": [
        {
          "code": "3060472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 5MM PAL-508LL",
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        {
          "code": "3060475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 379.2796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-FAST FIX 360 KPSC",
      "code_information": [
        {
          "code": "3060478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1344,
          "minimum": 282.24,
          "maximum": 984.0768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 688.8538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU RIGHT 7210424",
      "code_information": [
        {
          "code": "3060485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1334,
          "minimum": 280.14,
          "maximum": 976.7548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 683.7284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU LEFT 7210423",
      "code_information": [
        {
          "code": "3060486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.7393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STRT 7210426",
      "code_information": [
        {
          "code": "3060488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.7393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.3MM CROSSPIN 62-23333",
      "code_information": [
        {
          "code": "3060489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 749.3335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STR 7210425",
      "code_information": [
        {
          "code": "3060494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SILICONE 8CM        205108",
      "code_information": [
        {
          "code": "3061090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1750,
          "minimum": 367.5,
          "maximum": 1281.35,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 896.945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-SINGLE HOLE 1877-01-010",
      "code_information": [
        {
          "code": "3062492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2040,
          "minimum": 428.4,
          "maximum": 1493.688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1045.5816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-3' EPV100 VENT",
      "code_information": [
        {
          "code": "3068320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.1569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX PEDS MAXP",
      "code_information": [
        {
          "code": "3068323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP VIBRATORY ACAPELLA",
      "code_information": [
        {
          "code": "3068325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 509,
          "minimum": 106.89,
          "maximum": 372.6898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.8829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED W/7' TUBING",
      "code_information": [
        {
          "code": "3068327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BIPAP PERFORMATRAK LARGE",
      "code_information": [
        {
          "code": "3068330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT DUAL LIMB",
      "code_information": [
        {
          "code": "3068331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT CAPNOXYGEN C02-01",
      "code_information": [
        {
          "code": "3068332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT/PED 8’ 58051",
      "code_information": [
        {
          "code": "3068333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-MYOSURE            40-902",
      "code_information": [
        {
          "code": "3078533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 171,
          "minimum": 35.91,
          "maximum": 125.2062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.6443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-DURA           20-xxxx",
      "code_information": [
        {
          "code": "3078541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5964,
          "minimum": 1252.44,
          "maximum": 4366.8408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3056.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-DURAL           1314",
      "code_information": [
        {
          "code": "3078593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH INDWELLING SLIT 295-6",
      "code_information": [
        {
          "code": "3078730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 800.5875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-KARLEN BALLOON    CS-01700",
      "code_information": [
        {
          "code": "3078823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML 0797208",
      "code_information": [
        {
          "code": "3078850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU, DIALYSIS 2.5% 2L 5B9876",
      "code_information": [
        {
          "code": "3078852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 497,
          "minimum": 104.37,
          "maximum": 363.9034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 254.7324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML  07138-09",
      "code_information": [
        {
          "code": "3078858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 51,
          "minimum": 10.71,
          "maximum": 37.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.1395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK E3773-45C",
      "code_information": [
        {
          "code": "3078982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1254,
          "minimum": 263.34,
          "maximum": 918.1788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.7252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MAS TLIF LIGHT   3400033",
      "code_information": [
        {
          "code": "3079040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1462.2766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MULTILEAD TRIAL     3013",
      "code_information": [
        {
          "code": "3079055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1144,
          "minimum": 240.24,
          "maximum": 837.6368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 586.3458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.0X13        AR-8400EX",
      "code_information": [
        {
          "code": "3079215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 233.2057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.-X13 AR-8500EX",
      "code_information": [
        {
          "code": "3079228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 232.6932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER        20400161S/10",
      "code_information": [
        {
          "code": "3079240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 156.8372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL G2 TIP 35CM",
      "code_information": [
        {
          "code": "3079250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3329,
          "minimum": 699.09,
          "maximum": 2437.4938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1706.2457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 ABRADER    72201518",
      "code_information": [
        {
          "code": "3079252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 656,
          "minimum": 137.76,
          "maximum": 480.3232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.2262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR    72201513",
      "code_information": [
        {
          "code": "3079253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 326.488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3079254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 306.4989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5 FULL RADIUS 7205305",
      "code_information": [
        {
          "code": "3079257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 233.2057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-4.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3079259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.2358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 FULL RADIUM 7205306",
      "code_information": [
        {
          "code": "3079261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 226.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 INCISOR     7205345",
      "code_information": [
        {
          "code": "3079262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 226.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL 45CM    NSLG2C45A",
      "code_information": [
        {
          "code": "3079282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3167,
          "minimum": 665.07,
          "maximum": 2318.8774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1623.2142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 36\\\"   HAR36",
      "code_information": [
        {
          "code": "3079285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3146,
          "minimum": 660.66,
          "maximum": 2303.5012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1612.4508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HS FOCUS 9CM CRVD  HAR9F",
      "code_information": [
        {
          "code": "3079290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2871,
          "minimum": 602.91,
          "maximum": 2102.1462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1471.5023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INPUT 8FR PS    080011",
      "code_information": [
        {
          "code": "3079468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.6411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNLER SM-LG    9009-s",
      "code_information": [
        {
          "code": "3079475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 766,
          "minimum": 160.86,
          "maximum": 560.8652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 392.6056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-RENAL 20CM      900-123",
      "code_information": [
        {
          "code": "3079482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 221.4173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-EXT BILATERAL DYNJP8004A",
      "code_information": [
        {
          "code": "3079499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-CORNEAL DISP      E5699",
      "code_information": [
        {
          "code": "3079626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST-OP XL MALE      1315",
      "code_information": [
        {
          "code": "3079661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909504",
      "code_information": [
        {
          "code": "3079703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11962,
          "minimum": 2512.02,
          "maximum": 8758.5764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6131.0035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5070",
      "code_information": [
        {
          "code": "3079707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3761,
          "minimum": 789.81,
          "maximum": 2753.8042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1927.6629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5071",
      "code_information": [
        {
          "code": "3079709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3761,
          "minimum": 789.81,
          "maximum": 2753.8042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1927.6629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PHACO .9MM  8065-750517",
      "code_information": [
        {
          "code": "3079736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 429,
          "minimum": 90.09,
          "maximum": 314.1138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 219.8797,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SMALL VIT PLUS 1",
      "code_information": [
        {
          "code": "3079745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1675,
          "minimum": 351.75,
          "maximum": 1226.435,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 858.5045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STAR            AR-1606",
      "code_information": [
        {
          "code": "3079766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 877,
          "minimum": 184.17,
          "maximum": 642.1394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 449.4976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 12MM        CB12LT",
      "code_information": [
        {
          "code": "3079770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1106,
          "minimum": 232.26,
          "maximum": 809.8132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 566.8692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM KII          CFS22",
      "code_information": [
        {
          "code": "3079789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.5832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-FIBER          AR-7209SN",
      "code_information": [
        {
          "code": "3079790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM KII           CFS02",
      "code_information": [
        {
          "code": "3079791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM THREADED KII CTS22",
      "code_information": [
        {
          "code": "3079792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.5832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM THREADED KII  CTS0S",
      "code_information": [
        {
          "code": "3079793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.8559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATABLE OVAL",
      "code_information": [
        {
          "code": "3079795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 297,
          "minimum": 62.37,
          "maximum": 217.4634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.2244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SILICONE         400561",
      "code_information": [
        {
          "code": "3079975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 550,
          "minimum": 115.5,
          "maximum": 402.71,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 281.897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER MINI        1500",
      "code_information": [
        {
          "code": "3079992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 300.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER SMALL       1500",
      "code_information": [
        {
          "code": "3079994",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 554,
          "minimum": 116.34,
          "maximum": 405.6388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 283.9472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER PETITE      1500",
      "code_information": [
        {
          "code": "3079996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 300.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-AGGRESSIVE 3.5   283315",
      "code_information": [
        {
          "code": "3080062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 293.6854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ULTRA AGGRESSIVE 283325",
      "code_information": [
        {
          "code": "3080067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 293.6854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.5MM AR-1204AS-95",
      "code_information": [
        {
          "code": "3080073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2182,
          "minimum": 458.22,
          "maximum": 1597.6604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1118.3623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 10MM AR-1204AS-100",
      "code_information": [
        {
          "code": "3080074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1117.8497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.0MM AR1204AS90",
      "code_information": [
        {
          "code": "3080075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1819,
          "minimum": 381.99,
          "maximum": 1331.8718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 932.3103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-OPTIMOLD NASAL   PS1688",
      "code_information": [
        {
          "code": "3080204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.5299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3080355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 352,
          "minimum": 73.92,
          "maximum": 257.7344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 180.4141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-EGIA 60 MED   EGIA60AVM",
      "code_information": [
        {
          "code": "3080925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-ENDOCLIP MULTI    ER320",
      "code_information": [
        {
          "code": "3080932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 859,
          "minimum": 180.39,
          "maximum": 628.9598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 440.2719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR VASCULAR  TX30V",
      "code_information": [
        {
          "code": "3081085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 492.5509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT 12”",
      "code_information": [
        {
          "code": "3081101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT RIGHT",
      "code_information": [
        {
          "code": "3081102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY RT ANGLE Y PORT 12”",
      "code_information": [
        {
          "code": "3081103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL HEALTHVENT 24HR 97021",
      "code_information": [
        {
          "code": "3081122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 108.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIEDER TS101DC",
      "code_information": [
        {
          "code": "3081129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 594,
          "minimum": 124.74,
          "maximum": 434.9268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 304.4488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-POLYSORB 55      SZ 200",
      "code_information": [
        {
          "code": "3081173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4940,
          "minimum": 1037.4,
          "maximum": 3617.068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2531.9476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN INSORB 2030",
      "code_information": [
        {
          "code": "3081400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 894,
          "minimum": 187.74,
          "maximum": 654.5868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.2108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZS ECS's",
      "code_information": [
        {
          "code": "3081408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1763,
          "minimum": 370.23,
          "maximum": 1290.8686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 903.608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZ CDHxxA",
      "code_information": [
        {
          "code": "3081415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1570,
          "minimum": 329.7,
          "maximum": 1149.554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 804.6878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWER  PLEE60A",
      "code_information": [
        {
          "code": "3081416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2611,
          "minimum": 548.31,
          "maximum": 1911.7742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1338.2419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWERED PCE60A",
      "code_information": [
        {
          "code": "3081432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2475,
          "minimum": 519.75,
          "maximum": 1812.195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1268.5365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 45       EC45A",
      "code_information": [
        {
          "code": "3081433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2038,
          "minimum": 427.98,
          "maximum": 1492.2236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1044.5565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 60       EC60A",
      "code_information": [
        {
          "code": "3081436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2635,
          "minimum": 553.35,
          "maximum": 1929.347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1350.5429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-EGIA HANDLE  EGIAUSTND",
      "code_information": [
        {
          "code": "3081443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2985,
          "minimum": 626.85,
          "maximum": 2185.617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1529.9319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDO GIA UNIVER 030449",
      "code_information": [
        {
          "code": "3081491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1353.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-THICK TISSUE      TRT75",
      "code_information": [
        {
          "code": "3081494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3081502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT STR 35WD",
      "code_information": [
        {
          "code": "3081503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAYS-SURGICAL PACK    3311-8G",
      "code_information": [
        {
          "code": "3081506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER   TLC-75",
      "code_information": [
        {
          "code": "3081530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 60BL      TX60B",
      "code_information": [
        {
          "code": "3081535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 463.3362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR  40B     CS40B",
      "code_information": [
        {
          "code": "3081542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3019,
          "minimum": 633.99,
          "maximum": 2210.5118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1547.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40G      CS40G",
      "code_information": [
        {
          "code": "3081544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3019,
          "minimum": 633.99,
          "maximum": 2210.5118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1547.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDOPATH VASC PVE35A",
      "code_information": [
        {
          "code": "3081550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2231,
          "minimum": 468.51,
          "maximum": 1633.5382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1143.4767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-HEAVY WIRE 90    TLH90",
      "code_information": [
        {
          "code": "3081554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 791,
          "minimum": 166.11,
          "maximum": 579.1702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 405.4191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3081569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.6411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A28-2",
      "code_information": [
        {
          "code": "3082047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21603,
          "minimum": 4536.63,
          "maximum": 15817.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11072.4016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A25-25",
      "code_information": [
        {
          "code": "3082066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21603,
          "minimum": 4536.63,
          "maximum": 15817.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11072.4016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-AAA MAIN    ETCF3636C49E",
      "code_information": [
        {
          "code": "3082068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20042,
          "minimum": 4208.82,
          "maximum": 14674.7524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10272.3267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STICK-FIBER            AR-7209",
      "code_information": [
        {
          "code": "3082089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKINETTE-BARRIER   NON22535",
      "code_information": [
        {
          "code": "3082135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE FOOT        014407",
      "code_information": [
        {
          "code": "3082217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 659,
          "minimum": 138.39,
          "maximum": 482.5198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 337.7639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRAIGHT           1123",
      "code_information": [
        {
          "code": "3082330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUMP-PERICARDIAL 1/4 CONNECTOR",
      "code_information": [
        {
          "code": "3082395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.7697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURG-STRIP 1/2X6       80-1451",
      "code_information": [
        {
          "code": "3082416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 296,
          "minimum": 62.16,
          "maximum": 216.7312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.7118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPRALOOP-BRUCKER/MESSROGHLI",
      "code_information": [
        {
          "code": "3082421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1727,
          "minimum": 362.67,
          "maximum": 1264.5094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 885.1566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-NUKNITT 3X4      1943",
      "code_information": [
        {
          "code": "3082430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.2358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC-0       173024",
      "code_information": [
        {
          "code": "3082450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 441.8095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC 2-0 173023",
      "code_information": [
        {
          "code": "3082453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 441.8095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 698G",
      "code_information": [
        {
          "code": "3082542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-GORETEX CV-3      3N06A",
      "code_information": [
        {
          "code": "3082544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 423,
          "minimum": 88.83,
          "maximum": 309.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 216.8044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J947H",
      "code_information": [
        {
          "code": "3082558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONO PDSII        Z740D",
      "code_information": [
        {
          "code": "3082562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 305,
          "minimum": 64.05,
          "maximum": 223.321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 156.3247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ALIANCE        5060-05",
      "code_information": [
        {
          "code": "3082566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-FLOSEAL 10ML   1503352",
      "code_information": [
        {
          "code": "3082592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2592,
          "minimum": 544.32,
          "maximum": 1897.8624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1328.5037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING NEMA   3730ANS",
      "code_information": [
        {
          "code": "3082996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2024.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ACCESSORY           502",
      "code_information": [
        {
          "code": "3083003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4011,
          "minimum": 842.31,
          "maximum": 2936.8542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2055.7979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BIOGLUE 5ML  BG3515-5US",
      "code_information": [
        {
          "code": "3083007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5122,
          "minimum": 1075.62,
          "maximum": 3750.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2625.2299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANS CATH 10\\\" PM040-A",
      "code_information": [
        {
          "code": "3083014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1368,
          "minimum": 287.28,
          "maximum": 1001.6496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 701.1547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-CYSTO 25X5/8  581610",
      "code_information": [
        {
          "code": "3083019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 50,
          "minimum": 10.5,
          "maximum": 36.61,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 25.627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE VNUS        CFP",
      "code_information": [
        {
          "code": "3083021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION CATH  PM010-A",
      "code_information": [
        {
          "code": "3083022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 435,
          "minimum": 91.35,
          "maximum": 318.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 222.9549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION 5\\\"    PM020-A",
      "code_information": [
        {
          "code": "3083023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 307.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-COLLECTION   003984-901",
      "code_information": [
        {
          "code": "3083083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-STERIDRAPE 8 7/8   1075",
      "code_information": [
        {
          "code": "3083104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URETERAL DIAL   240-100",
      "code_information": [
        {
          "code": "3083141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1497,
          "minimum": 314.37,
          "maximum": 1096.1034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 767.2724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-PROTACK DEVICE 5MM",
      "code_information": [
        {
          "code": "3083191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3464,
          "minimum": 727.44,
          "maximum": 2536.3408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1775.4386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB AR-13226",
      "code_information": [
        {
          "code": "3083200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 596,
          "minimum": 125.16,
          "maximum": 436.3912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.4738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-BONE SCREW 3.5X50  311.349",
      "code_information": [
        {
          "code": "3083203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.35 2883-02-043",
      "code_information": [
        {
          "code": "3083212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1238.2966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-IQ DISPOSABLE 72-1010",
      "code_information": [
        {
          "code": "3083214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 481.7876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-GLOW AND TELL     1100-20",
      "code_information": [
        {
          "code": "3083225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 286.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-          AR-7237-7T",
      "code_information": [
        {
          "code": "3083486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 520,
          "minimum": 109.2,
          "maximum": 380.744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 266.5208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS2",
      "code_information": [
        {
          "code": "3083597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-BIOGLUE FAN        BGST-12",
      "code_information": [
        {
          "code": "3083615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 124.0347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE ALL    UMx67x's",
      "code_information": [
        {
          "code": "3083622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1067,
          "minimum": 224.07,
          "maximum": 781.2574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 546.8802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 35CM     3908",
      "code_information": [
        {
          "code": "3083637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CURVED DISP I&A 8065751512",
      "code_information": [
        {
          "code": "3083715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE POLYMER I/A",
      "code_information": [
        {
          "code": "3083720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 222,
          "minimum": 46.62,
          "maximum": 162.5484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 113.7839,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-TURBOSONICS     8065750853",
      "code_information": [
        {
          "code": "3083760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 382.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-VACURRETTE 5MM       21664",
      "code_information": [
        {
          "code": "3083764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.6411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-TUNNELING            1112",
      "code_information": [
        {
          "code": "3084399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 269.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-LUKI MUCOUS SPEC  8646-04",
      "code_information": [
        {
          "code": "3084800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 6",
      "code_information": [
        {
          "code": "3084821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 481.7876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA70",
      "code_information": [
        {
          "code": "3084824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 669.3772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA80",
      "code_information": [
        {
          "code": "3084827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1345,
          "minimum": 282.45,
          "maximum": 984.809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 689.3663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/METER ALL P4PxxSD",
      "code_information": [
        {
          "code": "3084870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1    4609764",
      "code_information": [
        {
          "code": "3084884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.9312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAPS-FINGER DISP PACK 9900s",
      "code_information": [
        {
          "code": "3084885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-LAP CB EXPLOR    G26908",
      "code_information": [
        {
          "code": "3084925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3560,
          "minimum": 747.6,
          "maximum": 2606.632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1824.6424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SOLU IRRISEPT .5% CHG",
      "code_information": [
        {
          "code": "3084928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 797,
          "minimum": 167.37,
          "maximum": 583.5634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 408.4944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INFLATION   03.804.413S",
      "code_information": [
        {
          "code": "3084946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP 26-23-0757",
      "code_information": [
        {
          "code": "3084992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.5363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFF74",
      "code_information": [
        {
          "code": "3085110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-100LP",
      "code_information": [
        {
          "code": "3085111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 906,
          "minimum": 190.26,
          "maximum": 663.3732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 464.3612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED     CTF73",
      "code_information": [
        {
          "code": "3085112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-100L",
      "code_information": [
        {
          "code": "3085113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 941,
          "minimum": 197.61,
          "maximum": 689.0002,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 482.3001,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREATED      CTF03",
      "code_information": [
        {
          "code": "3085117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-8MM KII OPTICAL   COQ19",
      "code_information": [
        {
          "code": "3085120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR47",
      "code_information": [
        {
          "code": "3085135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR85",
      "code_information": [
        {
          "code": "3085137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM KII OPTICAL  COR37",
      "code_information": [
        {
          "code": "3085140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 567,
          "minimum": 119.07,
          "maximum": 415.1574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 290.6102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM LONG         C0R39",
      "code_information": [
        {
          "code": "3085142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 567,
          "minimum": 119.07,
          "maximum": 415.1574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 290.6102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM KII FIOS      CFFxx",
      "code_information": [
        {
          "code": "3085145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM LONG BLADED CFB71",
      "code_information": [
        {
          "code": "3085160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-THORACOPOR 11.5  179303",
      "code_information": [
        {
          "code": "3085163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 882,
          "minimum": 185.22,
          "maximum": 645.8004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 452.0603,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM THREADED     CTF33",
      "code_information": [
        {
          "code": "3085165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-SPLIT           82-4095",
      "code_information": [
        {
          "code": "3085170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2007,
          "minimum": 421.47,
          "maximum": 1469.5254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1028.6678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL BLADELESS     B8LT",
      "code_information": [
        {
          "code": "3085202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 482,
          "minimum": 101.22,
          "maximum": 352.9204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 247.0443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP LONG VS101505",
      "code_information": [
        {
          "code": "3085203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1367,
          "minimum": 287.07,
          "maximum": 1000.9174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 700.6422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 5MM           B5LT",
      "code_information": [
        {
          "code": "3085207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1543,
          "minimum": 324.03,
          "maximum": 1129.7846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 790.8492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12X100MM     H12LP",
      "code_information": [
        {
          "code": "3085208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 702,
          "minimum": 147.42,
          "maximum": 514.0044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 359.8031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN CUFF 7.0MM",
      "code_information": [
        {
          "code": "3085522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.3922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BIO PREP BONE PREP",
      "code_information": [
        {
          "code": "3085533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1349,
          "minimum": 283.29,
          "maximum": 987.7378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 691.4165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SPIKE INFILTRATION",
      "code_information": [
        {
          "code": "3085534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.7697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 8.0FR MEGA IAB",
      "code_information": [
        {
          "code": "3085537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1496,
          "minimum": 314.16,
          "maximum": 1095.3712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 766.7598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ARMSTRONG TEFLON DRAIN",
      "code_information": [
        {
          "code": "3085540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-TIBIAL 111651",
      "code_information": [
        {
          "code": "3085541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PROCEDURE TRACKING 107130",
      "code_information": [
        {
          "code": "3085542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 698.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE 111320",
      "code_information": [
        {
          "code": "3085543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 405,
          "minimum": 85.05,
          "maximum": 296.541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 207.5787,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX IMPACTION",
      "code_information": [
        {
          "code": "3085544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 817,
          "minimum": 171.57,
          "maximum": 598.2074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 418.7452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144140",
      "code_information": [
        {
          "code": "3085545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 484.3503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX 116230",
      "code_information": [
        {
          "code": "3085546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 481.7876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON ULTRASIL",
      "code_information": [
        {
          "code": "3085560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.1678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-ENDO EXCEL 15MM   B15LT",
      "code_information": [
        {
          "code": "3085620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1548,
          "minimum": 325.08,
          "maximum": 1133.4456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 793.4119,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR ARMSTRONG    10-56121",
      "code_information": [
        {
          "code": "3085635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 109.6836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR PAPARELLA 1.14MM",
      "code_information": [
        {
          "code": "3085636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 109.6836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACHEAL EMG  8229307",
      "code_information": [
        {
          "code": "3085638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1585,
          "minimum": 332.85,
          "maximum": 1160.537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 812.3759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH ALL SZS 822970x",
      "code_information": [
        {
          "code": "3085644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1414.0979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 20FR   0100-20",
      "code_information": [
        {
          "code": "3085648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-KAMVAC            5300-00",
      "code_information": [
        {
          "code": "3085723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 452.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MOSS GASTROSTOMY  5-17719",
      "code_information": [
        {
          "code": "3085779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 946.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM PROX",
      "code_information": [
        {
          "code": "3085796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 346.477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T MODIFIED        24-0072",
      "code_information": [
        {
          "code": "3085882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.9877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COLLECTION DISP BKT-506",
      "code_information": [
        {
          "code": "3086006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.7871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OXYFLEX        SA008000",
      "code_information": [
        {
          "code": "3086095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX INFLOW  AQL-110",
      "code_information": [
        {
          "code": "3086102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      80-9102",
      "code_information": [
        {
          "code": "3086103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 715,
          "minimum": 150.15,
          "maximum": 523.523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.4661,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      5120-10",
      "code_information": [
        {
          "code": "3086105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 117.3717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AIRSEAL ASM-EVAC",
      "code_information": [
        {
          "code": "3086106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 963,
          "minimum": 202.23,
          "maximum": 705.1086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 493.576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATOR STR  18-95522",
      "code_information": [
        {
          "code": "3086107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 542,
          "minimum": 113.82,
          "maximum": 396.8524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 277.7967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LASER VACUUM    VT10424",
      "code_information": [
        {
          "code": "3086109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.9781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LIPOSUCTION   DYND50112",
      "code_information": [
        {
          "code": "3086110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MAIN PUMP       AR-6410",
      "code_information": [
        {
          "code": "3086111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 392.0931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/4\\\"X1/16\\\"X8'      3108",
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        {
          "code": "3086139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 132,
          "minimum": 27.72,
          "maximum": 96.6504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.6553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OUTFLOW         AR-6430",
      "code_information": [
        {
          "code": "3086141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO      284508",
      "code_information": [
        {
          "code": "3086142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 94.5,
          "maximum": 329.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 230.643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO IRRIG OUT",
      "code_information": [
        {
          "code": "3086144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 312.1369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-ASPIRATION AT-10003-6",
      "code_information": [
        {
          "code": "3086181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.9704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TISSEEL         0600065",
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        {
          "code": "3086182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 629,
          "minimum": 132.09,
          "maximum": 460.5538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 322.3877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TRANSDUCER 48 61000",
      "code_information": [
        {
          "code": "3086185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.0456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARTHREX-TIB CANN      AR-1802D",
      "code_information": [
        {
          "code": "3086190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.7369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-& TIP-SMALL   9009-18",
      "code_information": [
        {
          "code": "3086203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 821,
          "minimum": 172.41,
          "maximum": 601.1362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 420.7953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER & TIP-LARGE   9009-16",
      "code_information": [
        {
          "code": "3086205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 724,
          "minimum": 152.04,
          "maximum": 530.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 371.079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-STIMULATOR LEAD   402",
      "code_information": [
        {
          "code": "3086210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3245,
          "minimum": 681.45,
          "maximum": 2375.989,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1663.1923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE SUPPORT 79-82160",
      "code_information": [
        {
          "code": "3086407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 70x-xxxx ALL SIZES",
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        {
          "code": "3086409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.8655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM VAS          XR30V",
      "code_information": [
        {
          "code": "3086955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 443,
          "minimum": 93.03,
          "maximum": 324.3646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 227.0552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH 2-0   170057",
      "code_information": [
        {
          "code": "3086965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 813,
          "minimum": 170.73,
          "maximum": 595.2786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 416.695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VAC-SUPER TURBO     ASC4250-01",
      "code_information": [
        {
          "code": "3087110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 749.3335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP CVD ALL 21500s",
      "code_information": [
        {
          "code": "3087119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CURVED 7MM     21853",
      "code_information": [
        {
          "code": "3087130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 8MM CVD   20317",
      "code_information": [
        {
          "code": "3087132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VOICE-PROLARYN        8044M0K5",
      "code_information": [
        {
          "code": "3087140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3836,
          "minimum": 805.56,
          "maximum": 2808.7192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1966.1034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVULATOME-LEMAITRE   1009-00",
      "code_information": [
        {
          "code": "3087919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 13534,
          "minimum": 2842.14,
          "maximum": 9909.5948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6936.7164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8916-14",
      "code_information": [
        {
          "code": "3087939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 812,
          "minimum": 170.52,
          "maximum": 594.5464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 416.1825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 UNDYED    VLOCM1904",
      "code_information": [
        {
          "code": "3088955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 277.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J761D",
      "code_information": [
        {
          "code": "3088965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.2823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VIOLET    VLOCM0804",
      "code_information": [
        {
          "code": "3088967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 557,
          "minimum": 116.97,
          "maximum": 407.8354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 285.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0    MCP496G",
      "code_information": [
        {
          "code": "3088972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J441",
      "code_information": [
        {
          "code": "3088976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6.1505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS2     1666G",
      "code_information": [
        {
          "code": "3088979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J218H",
      "code_information": [
        {
          "code": "3088985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y495G",
      "code_information": [
        {
          "code": "3088991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       D5526",
      "code_information": [
        {
          "code": "3088992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 799,
          "minimum": 167.79,
          "maximum": 585.0278,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 6-0           Z432H",
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        {
          "code": "3088993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.44,
          "maximum": 46.8608,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0  ALL  833-000s",
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        {
          "code": "3088998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J727D",
      "code_information": [
        {
          "code": "3089002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J905T",
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        {
          "code": "3089005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J739D",
      "code_information": [
        {
          "code": "3089007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J906G",
      "code_information": [
        {
          "code": "3089013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.8559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J740D",
      "code_information": [
        {
          "code": "3089014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J775D",
      "code_information": [
        {
          "code": "3089024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J789D",
      "code_information": [
        {
          "code": "3089025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 110.7086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z881G",
      "code_information": [
        {
          "code": "3089026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8806H",
      "code_information": [
        {
          "code": "3089027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z990G",
      "code_information": [
        {
          "code": "3089030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.2038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J834G",
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        {
          "code": "3089039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J833G",
      "code_information": [
        {
          "code": "3089042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8824G",
      "code_information": [
        {
          "code": "3089048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 30.2399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y493G",
      "code_information": [
        {
          "code": "3089059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y490G",
      "code_information": [
        {
          "code": "3089060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 51.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8521H",
      "code_information": [
        {
          "code": "3089064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8581H",
      "code_information": [
        {
          "code": "3089065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 53.3042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8557H",
      "code_information": [
        {
          "code": "3089066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8833H",
      "code_information": [
        {
          "code": "3089069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8623H",
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        {
          "code": "3089072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8522H",
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        {
          "code": "3089073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8534H",
      "code_information": [
        {
          "code": "3089074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J904T",
      "code_information": [
        {
          "code": "3089079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      PX82H",
      "code_information": [
        {
          "code": "3089097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8523H",
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        {
          "code": "3089100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8706H",
      "code_information": [
        {
          "code": "3089103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8805H",
      "code_information": [
        {
          "code": "3089105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8709H",
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        {
          "code": "3089106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 55.86,
          "maximum": 194.7652,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8720H",
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        {
          "code": "3089110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8556H",
      "code_information": [
        {
          "code": "3089113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 19.11,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8710H",
      "code_information": [
        {
          "code": "3089114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8304H",
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        {
          "code": "3089117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 50.4,
          "maximum": 175.728,
          "payers_information": [
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8703H",
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        {
          "code": "3089121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 52.71,
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          "payers_information": [
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J213H",
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        {
          "code": "3089123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO       AR-4068-xxx",
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        {
          "code": "3089131",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 749.3335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         G124H",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 12.18,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "3089145",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       1792G",
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        {
          "code": "3089146",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 52.08,
          "maximum": 181.5856,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 127.1099,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 0       L104G",
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        {
          "code": "3089150",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.65,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       G172H",
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        {
          "code": "3089154",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 56.8919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U203",
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        {
          "code": "3089156",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 31.2649,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-CHROMIC 4-0       1637G",
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        {
          "code": "3089157",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-PLAIN GUT 6-0     1916G",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "3089172",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 11.76,
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          "payers_information": [
            {
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "3089195",
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        },
        {
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        }
      ],
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        {
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          "minimum": 17.64,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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          "code": "3089202",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 24.78,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-ETHIBOND 0  X524H",
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        {
          "code": "3089204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5        B449T",
      "code_information": [
        {
          "code": "3089212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 4-0      X204H",
      "code_information": [
        {
          "code": "3089217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 3-0      X936H",
      "code_information": [
        {
          "code": "3089226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5-0      X727H",
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        {
          "code": "3089227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        690G",
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        {
          "code": "3089238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       1666H",
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        {
          "code": "3089239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1663H",
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        {
          "code": "3089244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z340H",
      "code_information": [
        {
          "code": "3089254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5.1254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 0         L880G",
      "code_information": [
        {
          "code": "3089258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.3151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      SXP82",
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        {
          "code": "3089266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 607,
          "minimum": 127.47,
          "maximum": 444.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND2-0       SXP86",
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        {
          "code": "3089267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 666,
          "minimum": 139.86,
          "maximum": 487.6452,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 341.3516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X927H",
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        {
          "code": "3089281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z879G",
      "code_information": [
        {
          "code": "3089283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0 Z494G",
      "code_information": [
        {
          "code": "3089284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.0534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y497G",
      "code_information": [
        {
          "code": "3089286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.6411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0        687G",
      "code_information": [
        {
          "code": "3089287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.1788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X513H",
      "code_information": [
        {
          "code": "3089288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.29,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2 MX69G",
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        {
          "code": "3089290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.7086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS O EZ10G",
      "code_information": [
        {
          "code": "3089291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          EJ10G",
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        {
          "code": "3089292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       M8720",
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        {
          "code": "3089293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 622,
          "minimum": 130.62,
          "maximum": 455.4284,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       M8303",
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        {
          "code": "3089294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 778,
          "minimum": 163.38,
          "maximum": 569.6516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 398.7561,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       U202H",
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        {
          "code": "3089307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U213H",
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        {
          "code": "3089308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8843H",
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        {
          "code": "3089314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 45.6161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J555G",
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        {
          "code": "3089316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            C027D",
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        {
          "code": "3089318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX45D",
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        {
          "code": "3089320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 43.47,
          "maximum": 151.5654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 106.0958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 8-0         2815G",
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        {
          "code": "3089323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X523H",
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        {
          "code": "3089324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.29,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X977H",
      "code_information": [
        {
          "code": "3089325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 5-0     1915G",
      "code_information": [
        {
          "code": "3089326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0           Z774D",
      "code_information": [
        {
          "code": "3089328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.7871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 10-0      9003G",
      "code_information": [
        {
          "code": "3089335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.7479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        793G",
      "code_information": [
        {
          "code": "3089348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 98.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 699G",
      "code_information": [
        {
          "code": "3089354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON/MONO    ETH562H",
      "code_information": [
        {
          "code": "3089357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 CT1  J-945-H",
      "code_information": [
        {
          "code": "3089362",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5.1254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0        585H",
      "code_information": [
        {
          "code": "3089363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C0125",
      "code_information": [
        {
          "code": "3089364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMD2B413",
      "code_information": [
        {
          "code": "3089371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.0379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPD2B408",
      "code_information": [
        {
          "code": "3089372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.8012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       U204H",
      "code_information": [
        {
          "code": "3089379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J428H",
      "code_information": [
        {
          "code": "3089381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 46,
          "minimum": 9.66,
          "maximum": 33.6812,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 23.5768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6/0 P-1    J489G",
      "code_information": [
        {
          "code": "3089382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 7-0        J488G",
      "code_information": [
        {
          "code": "3089384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPP1A400",
      "code_information": [
        {
          "code": "3089386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 370,
          "minimum": 77.7,
          "maximum": 270.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.6398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2.0 ALL PX83Hs",
      "code_information": [
        {
          "code": "3089390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1654G",
      "code_information": [
        {
          "code": "3089394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NUROLON 4-0       C584D",
      "code_information": [
        {
          "code": "3089396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 236,
          "minimum": 49.56,
          "maximum": 172.7992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 120.9594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPD2B413",
      "code_information": [
        {
          "code": "3089403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 391,
          "minimum": 82.11,
          "maximum": 286.2902,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 200.4031,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z493G",
      "code_information": [
        {
          "code": "3089407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN 4-0 1644G",
      "code_information": [
        {
          "code": "3089408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE RS23",
      "code_information": [
        {
          "code": "3089410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC PBT xxMM",
      "code_information": [
        {
          "code": "3089416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 349.0397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1B406",
      "code_information": [
        {
          "code": "3089420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 380,
          "minimum": 79.8,
          "maximum": 278.236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 194.7652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MONOPTY 16GX20CM",
      "code_information": [
        {
          "code": "3089701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 190.6649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE EICA8875-01",
      "code_information": [
        {
          "code": "3090040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2017,
          "minimum": 423.57,
          "maximum": 1476.8474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1033.7932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-TURBINATE RED EICA4845-01",
      "code_information": [
        {
          "code": "3090049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2053,
          "minimum": 431.13,
          "maximum": 1503.2066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1052.2446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,TOPAZ MICRO ACH4041-0",
      "code_information": [
        {
          "code": "3090061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1376.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .045      WS-1106ST",
      "code_information": [
        {
          "code": "3090191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER #2          AR-7200",
      "code_information": [
        {
          "code": "3091195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 185.0269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER 2-0         AR-7220",
      "code_information": [
        {
          "code": "3091196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 185.0269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5         310.243",
      "code_information": [
        {
          "code": "3091211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 436.6841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.8MM        292.68",
      "code_information": [
        {
          "code": "3091218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 623,
          "minimum": 130.83,
          "maximum": 456.1606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 319.3124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6MM AGK16150",
      "code_information": [
        {
          "code": "3091237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-2.5MM DRILL XFO082501",
      "code_information": [
        {
          "code": "3091238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE          1806-0080S",
      "code_information": [
        {
          "code": "3091250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1197,
          "minimum": 251.37,
          "maximum": 876.4434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 613.5104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3091317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .054          WS-1406ST",
      "code_information": [
        {
          "code": "3091319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K              0152-0218S",
      "code_information": [
        {
          "code": "3091346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 881,
          "minimum": 185.01,
          "maximum": 645.0682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 451.5477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 040-365",
      "code_information": [
        {
          "code": "3091419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1510,
          "minimum": 317.1,
          "maximum": 1105.622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 773.9354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 046-072",
      "code_information": [
        {
          "code": "3091422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 357,
          "minimum": 74.97,
          "maximum": 261.3954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 182.9768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY    047-032",
      "code_information": [
        {
          "code": "3091425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 295,
          "minimum": 61.95,
          "maximum": 215.999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 151.1993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE TIP      03.211.410",
      "code_information": [
        {
          "code": "3091436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 616,
          "minimum": 129.36,
          "maximum": 451.0352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 315.7246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 5.0 310.63",
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        {
          "code": "3091500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3340,
          "minimum": 701.4,
          "maximum": 2445.548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1711.8836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 21665",
      "code_information": [
        {
          "code": "3091501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION SEID",
      "code_information": [
        {
          "code": "3091510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 890,
          "minimum": 186.9,
          "maximum": 651.658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 456.1606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND M 2.5MM 03.000.007S",
      "code_information": [
        {
          "code": "3091511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 405.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/2X3/32 /10 3610",
      "code_information": [
        {
          "code": "3091513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLUE-GUN CMS REVOLUTION",
      "code_information": [
        {
          "code": "3091516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1029,
          "minimum": 216.09,
          "maximum": 753.4338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 527.4037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT 5MM EB210",
      "code_information": [
        {
          "code": "3091517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1169.6163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT FINE EB230",
      "code_information": [
        {
          "code": "3091518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2953,
          "minimum": 620.13,
          "maximum": 2162.1866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1513.5306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE CANNU FLEX .042X12",
      "code_information": [
        {
          "code": "3091560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 289.0726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TEMPORARY CARDIA  024-100",
      "code_information": [
        {
          "code": "3091561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.7337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8MM FIBULA ROD 80-0642",
      "code_information": [
        {
          "code": "3091572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 669.3772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-FACIAL DENTAL 714-6IN-GEL",
      "code_information": [
        {
          "code": "3093187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 249,
          "minimum": 52.29,
          "maximum": 182.3178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 127.6225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ACCESSORY       3550-02",
      "code_information": [
        {
          "code": "3093195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 481.7876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOBUTTON-CL ULTRA PAC 1.2",
      "code_information": [
        {
          "code": "3094000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2461,
          "minimum": 516.81,
          "maximum": 1801.9442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1261.3609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACCESSORY-TIP COVER     400180",
      "code_information": [
        {
          "code": "3100010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SNAPFIT 15 DEG    400152",
      "code_information": [
        {
          "code": "3102750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCL0316",
      "code_information": [
        {
          "code": "3115410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 277.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCM1545",
      "code_information": [
        {
          "code": "3115420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 277.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA ARM        420279",
      "code_information": [
        {
          "code": "3115515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA HEAD       420273",
      "code_information": [
        {
          "code": "3115525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM    420015",
      "code_information": [
        {
          "code": "3115580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM XI 470015",
      "code_information": [
        {
          "code": "3115585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 652,
          "minimum": 136.92,
          "maximum": 477.3944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 334.1761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT COLUMN 470341",
      "code_information": [
        {
          "code": "3115590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.5363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM LONG XI   470358",
      "code_information": [
        {
          "code": "3155025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 192.715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM XI        470357",
      "code_information": [
        {
          "code": "3155030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 192.715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 5MM        400161",
      "code_information": [
        {
          "code": "3170005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 8.5-13MM   420206",
      "code_information": [
        {
          "code": "3170007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA            400077",
      "code_information": [
        {
          "code": "3170010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA ENDOWRIST XI",
      "code_information": [
        {
          "code": "3170020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-8MM XI 570361",
      "code_information": [
        {
          "code": "3170050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.5363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL s.I.e.    410322",
      "code_information": [
        {
          "code": "3170060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.5968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL XI        480322",
      "code_information": [
        {
          "code": "3170070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.5968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUB. & FILTER 20400162S/10",
      "code_information": [
        {
          "code": "3171250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 156.8372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-ENDOWRIST STAPLER 45",
      "code_information": [
        {
          "code": "3171320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909506",
      "code_information": [
        {
          "code": "3171350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11962,
          "minimum": 2512.02,
          "maximum": 8758.5764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6131.0035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 12M OMS-T12BT",
      "code_information": [
        {
          "code": "3175750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1756,
          "minimum": 368.76,
          "maximum": 1285.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 900.0202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-SINGLE SITE 8.5    428065",
      "code_information": [
        {
          "code": "3185345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1488,
          "minimum": 312.48,
          "maximum": 1089.5136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 762.6595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEXIBLE         3100A",
      "code_information": [
        {
          "code": "3240013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1449,
          "minimum": 304.29,
          "maximum": 1060.9578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 742.6705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GENERATOR INFANT LP FLOW",
      "code_information": [
        {
          "code": "3240072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 596,
          "minimum": 125.16,
          "maximum": 436.3912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.4738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INFANT O2 DELIVERY   RT329",
      "code_information": [
        {
          "code": "3240073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 476,
          "minimum": 99.96,
          "maximum": 348.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 243.969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RESUS S/USE       900RD010",
      "code_information": [
        {
          "code": "3240075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG HYDROGEL",
      "code_information": [
        {
          "code": "3240083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODES-EEG LOW IMPEDENCE",
      "code_information": [
        {
          "code": "3240085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTERFACE-TRACHEOSTOMY HI FLOW",
      "code_information": [
        {
          "code": "3240105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.6006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BELLOWS & WATER TRAP 3100A",
      "code_information": [
        {
          "code": "3240167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.2358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CONNECTING TUBING.   3100",
      "code_information": [
        {
          "code": "3240170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.5003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 6 FR    196",
      "code_information": [
        {
          "code": "3249995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 8 FR    198",
      "code_information": [
        {
          "code": "3249997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE MAC 5FR    1925",
      "code_information": [
        {
          "code": "3249998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE 14FR 12\\\" 220135",
      "code_information": [
        {
          "code": "3250000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.5299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT UNCUFFED",
      "code_information": [
        {
          "code": "3281990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.2358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3282370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XS      006950",
      "code_information": [
        {
          "code": "3283013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP THERAPY  \\\"ACAPELLA\\\"",
      "code_information": [
        {
          "code": "3283015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.4392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION  LG     006965",
      "code_information": [
        {
          "code": "3283017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XLG     006970",
      "code_information": [
        {
          "code": "3283018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUVETTE-CO2 DISP ADULT MP01062",
      "code_information": [
        {
          "code": "3284354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 101.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER 5MM",
      "code_information": [
        {
          "code": "3290045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL MED HIGH FLOW",
      "code_information": [
        {
          "code": "3290046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.9877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL SM HIGH FLOW",
      "code_information": [
        {
          "code": "3290047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL LG HIGH FLOW",
      "code_information": [
        {
          "code": "3290048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP           23-0757",
      "code_information": [
        {
          "code": "3290060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 155.8122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT L599-130",
      "code_information": [
        {
          "code": "3290061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT W/MR290 SINGLE",
      "code_information": [
        {
          "code": "3290062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 370,
          "minimum": 77.7,
          "maximum": 270.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.6398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BREATHING NEONATAL",
      "code_information": [
        {
          "code": "3290074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-INFANT DUAL FLOW RT26",
      "code_information": [
        {
          "code": "3290077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 226.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOWMETER-PEAK          002068",
      "code_information": [
        {
          "code": "3290080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.8559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-CPAP NASAL NSC-001",
      "code_information": [
        {
          "code": "3290082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.58,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOW-CONT CYSTO GREENLYT",
      "code_information": [
        {
          "code": "3290084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP MED",
      "code_information": [
        {
          "code": "3290127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP SMALL",
      "code_information": [
        {
          "code": "3290128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOSE-AIR MODEL 205 DISP",
      "code_information": [
        {
          "code": "3290145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED SM NIV",
      "code_information": [
        {
          "code": "3290170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED MED NIV",
      "code_information": [
        {
          "code": "3290171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED LG NIV",
      "code_information": [
        {
          "code": "3290172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 42MM    RD804-10",
      "code_information": [
        {
          "code": "3290178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP AIRLIFE W/FILTER",
      "code_information": [
        {
          "code": "3290184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.4296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL XS INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 309,
          "minimum": 64.89,
          "maximum": 226.2498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 158.3749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL LG INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL MED INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 146.0739,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 308,
          "minimum": 64.68,
          "maximum": 225.5176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 157.8623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 60MM    RD806-10",
      "code_information": [
        {
          "code": "3290194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK,OXY ADULT OM-1125-8",
      "code_information": [
        {
          "code": "3290214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED SMALL NIV",
      "code_information": [
        {
          "code": "3290215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.3607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.7871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED LARGE NIV",
      "code_information": [
        {
          "code": "3290217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.3607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 118.3967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED LG NIV",
      "code_information": [
        {
          "code": "3290219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.6977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP ALOHA ALO100",
      "code_information": [
        {
          "code": "3290220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 704,
          "minimum": 147.84,
          "maximum": 515.4688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 360.8282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-MISTY FINITY  002534",
      "code_information": [
        {
          "code": "3290245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 119,
          "minimum": 24.99,
          "maximum": 87.1318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 60.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOPPER-DECANNULATION SZ4",
      "code_information": [
        {
          "code": "3290354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 760,
          "minimum": 159.6,
          "maximum": 556.472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 389.5304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DIRECTIONAL BALLARD  22059",
      "code_information": [
        {
          "code": "3290385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 5MM PROX",
      "code_information": [
        {
          "code": "3290400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 699,
          "minimum": 146.79,
          "maximum": 511.8078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 358.2655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY SLT UNCUFF 5MM",
      "code_information": [
        {
          "code": "3290401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 679,
          "minimum": 142.59,
          "maximum": 497.1638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 348.0147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEST-SPU ALL SZS  WRAP-SLOTTED",
      "code_information": [
        {
          "code": "3290504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 819,
          "minimum": 171.99,
          "maximum": 599.6718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 419.7703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING WHITE    PMV005",
      "code_information": [
        {
          "code": "3290506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 876,
          "minimum": 183.96,
          "maximum": 641.4072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 448.985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING PURPLE  PMV2001",
      "code_information": [
        {
          "code": "3290508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 875,
          "minimum": 183.75,
          "maximum": 640.675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 448.4725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP LPEEP",
      "code_information": [
        {
          "code": "3290509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP ADJ          2K8082",
      "code_information": [
        {
          "code": "3290515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-THERAPRESSURE     262895",
      "code_information": [
        {
          "code": "3300010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 51,
          "minimum": 10.71,
          "maximum": 37.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.1395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOFT GOODS FOR CPM UNIT",
      "code_information": [
        {
          "code": "3302945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 168.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA VARICEX S",
      "code_information": [
        {
          "code": "3310024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-ENDURA KIT         775410",
      "code_information": [
        {
          "code": "3310985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.3935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BGE   A840235",
      "code_information": [
        {
          "code": "3310986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.58,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BLACK  554617",
      "code_information": [
        {
          "code": "3310987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.4688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX RED   A840241",
      "code_information": [
        {
          "code": "3310989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 6CMX5CM",
      "code_information": [
        {
          "code": "3310991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 8CMX5CM",
      "code_information": [
        {
          "code": "3310992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 10CMX5M",
      "code_information": [
        {
          "code": "3310993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDL K 12CMX5M",
      "code_information": [
        {
          "code": "3311000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL 15CMX.4CMX2.5M",
      "code_information": [
        {
          "code": "3311010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ12 12CM",
      "code_information": [
        {
          "code": "3311075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 290,
          "minimum": 60.9,
          "maximum": 212.338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 148.6366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ7 7CM",
      "code_information": [
        {
          "code": "3311076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL SOFT",
      "code_information": [
        {
          "code": "3311078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING C",
      "code_information": [
        {
          "code": "3311085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 116.3466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AID-\\\"CLEAN EASY\\\" GRIP REACH",
      "code_information": [
        {
          "code": "3311086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 143.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING D",
      "code_information": [
        {
          "code": "3311094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.7337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3311107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-LG HDL      C6298-01-25",
      "code_information": [
        {
          "code": "3311117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 53,
          "minimum": 11.13,
          "maximum": 38.8066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.1646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3311123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 6CMX5M",
      "code_information": [
        {
          "code": "3311138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 8CMX5M RL",
      "code_information": [
        {
          "code": "3311139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-IONTOPHOR IOGEL 2971",
      "code_information": [
        {
          "code": "3311144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYBRESIS PATCH",
      "code_information": [
        {
          "code": "3311150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALU 1.5X3.5 PK 2393",
      "code_information": [
        {
          "code": "3311153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ALUM LTX FREE ALL",
      "code_information": [
        {
          "code": "3311156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.4437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXERCISER-POWER GRIP HAND",
      "code_information": [
        {
          "code": "3311157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-COMFY HAND/THUMB",
      "code_information": [
        {
          "code": "3311158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 723,
          "minimum": 151.83,
          "maximum": 529.3806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 370.5664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3311161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUTRODE RND 1.25\\\"",
      "code_information": [
        {
          "code": "3311163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT OVAL PK 2\\\"X4\\\"",
      "code_information": [
        {
          "code": "3311164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-WEIGHTED EZ GRIP 920675",
      "code_information": [
        {
          "code": "3311165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELECTRODE ADULT       9050",
      "code_information": [
        {
          "code": "3311167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3311174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.6977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT SQ PK  1.5X3.5",
      "code_information": [
        {
          "code": "3311178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.8276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT M&LGE",
      "code_information": [
        {
          "code": "3311191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARD-FOOD INVISIBLE      1115",
      "code_information": [
        {
          "code": "3311192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-TRACTION EXER ALL C5032s",
      "code_information": [
        {
          "code": "3311193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.4688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT S&XS",
      "code_information": [
        {
          "code": "3311194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LAVAGE    0210112000",
      "code_information": [
        {
          "code": "3311197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 504,
          "minimum": 105.84,
          "maximum": 369.0288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 258.3202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPM SOFTGOOD FOR HOME UNIT",
      "code_information": [
        {
          "code": "3311235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 168.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3311250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.5003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HIP/KNEE W/26 REACHER",
      "code_information": [
        {
          "code": "3311251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH UPPER EXTREMITY",
      "code_information": [
        {
          "code": "3311255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-ELASTO-GEL CAST/SPL  A8273",
      "code_information": [
        {
          "code": "3311340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.6521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3311347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3311357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-D WRIST BRACE ALL SIZES",
      "code_information": [
        {
          "code": "3311363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.9813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADDING-FOAM \\\"KOMPREX\\\" SHEET",
      "code_information": [
        {
          "code": "3311369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPOON-WEIGHTED EZ GRIP 920688",
      "code_information": [
        {
          "code": "3311406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-LONG-32\\\"       A665009",
      "code_information": [
        {
          "code": "3311472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-ALUMINUM 32\\\"      4107",
      "code_information": [
        {
          "code": "3311475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.6521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-STANDARD 26\\\"    A80-42",
      "code_information": [
        {
          "code": "3311479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-SAMMONS PRESTON   4109",
      "code_information": [
        {
          "code": "3311480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINTING-EZEFORM 1/8”X18”X24”",
      "code_information": [
        {
          "code": "3311600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 475,
          "minimum": 99.75,
          "maximum": 347.795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 243.4565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELBOW NEOPRENE XL",
      "code_information": [
        {
          "code": "3311602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.0816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-JOINT JACK MED   A52542",
      "code_information": [
        {
          "code": "3311613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.0237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 6\\\"-7\\\"",
      "code_information": [
        {
          "code": "3311625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.8012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 3-14",
      "code_information": [
        {
          "code": "3311701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT S/M A812731",
      "code_information": [
        {
          "code": "3311702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 190.6649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND COMFY LG ADULT",
      "code_information": [
        {
          "code": "3311703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 444,
          "minimum": 93.24,
          "maximum": 325.0968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 227.5678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT/LARGE DYNAPRO",
      "code_information": [
        {
          "code": "3311704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 382.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-STABILIZER WALKER ROLYAN",
      "code_information": [
        {
          "code": "3311708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 463,
          "minimum": 97.23,
          "maximum": 339.0086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 237.306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WALKER HIGH OVATION LRG",
      "code_information": [
        {
          "code": "3311709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 281.3845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-LMB FINGER HUGGER",
      "code_information": [
        {
          "code": "3312530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 125.5723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EZEFORM-ANTI MICROBIAL 564393",
      "code_information": [
        {
          "code": "3315521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 572,
          "minimum": 120.12,
          "maximum": 418.8184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 293.1729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3397811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.8765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PALM SHIELD RIGHT",
      "code_information": [
        {
          "code": "3397815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND RIGHT/MED A31228",
      "code_information": [
        {
          "code": "3397817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT MED A31227",
      "code_information": [
        {
          "code": "3397818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SYRINGE SSS-STP-SP",
      "code_information": [
        {
          "code": "3500008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.1067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SOFTGOODS CPM        20533",
      "code_information": [
        {
          "code": "3500038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.5755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "3500087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LMA DISP ALL SZ  1250xx",
      "code_information": [
        {
          "code": "3500245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 34FR  123034",
      "code_information": [
        {
          "code": "3500275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 28F   123028",
      "code_information": [
        {
          "code": "3500280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 26FR  123026",
      "code_information": [
        {
          "code": "3500283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 30FR  123030",
      "code_information": [
        {
          "code": "3500285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 32FR  123032",
      "code_information": [
        {
          "code": "3500288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACMENT KNEE COLD L/XL",
      "code_information": [
        {
          "code": "3500410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED & 60MM AIRWAY",
      "code_information": [
        {
          "code": "3500786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT & 90MM AIRWY",
      "code_information": [
        {
          "code": "3500788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASPIRATOR-MECONIUM HCI   N0101",
      "code_information": [
        {
          "code": "3500789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-INFANT  5442160xx",
      "code_information": [
        {
          "code": "3500792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-COLLECTION 4X8 BX     9778",
      "code_information": [
        {
          "code": "3500815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    C0135T",
      "code_information": [
        {
          "code": "3501012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.6161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0        697H",
      "code_information": [
        {
          "code": "3501065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 FS-3  1665G",
      "code_information": [
        {
          "code": "3501070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXTERNAL CSF DRAIN INS8700",
      "code_information": [
        {
          "code": "3501130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 448,
          "minimum": 94.08,
          "maximum": 328.0256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 229.6179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC VERALNK ULTLNK500",
      "code_information": [
        {
          "code": "3501755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 666,
          "minimum": 139.86,
          "maximum": 487.6452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 341.3516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18FR5CC 0119L18",
      "code_information": [
        {
          "code": "3501790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC       6261",
      "code_information": [
        {
          "code": "3502002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EFFLUENT 5L PRISMAFLEX",
      "code_information": [
        {
          "code": "3502007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 20F30C  0167L20",
      "code_information": [
        {
          "code": "3502010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL   TCS1000",
      "code_information": [
        {
          "code": "3502048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 369,
          "minimum": 77.49,
          "maximum": 270.1818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 189.1273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 400     7000LL",
      "code_information": [
        {
          "code": "3502063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST MED RIGHT 5001-0",
      "code_information": [
        {
          "code": "3502580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LARGE RT  5001-04",
      "code_information": [
        {
          "code": "3502590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-LIFEBAND FOR AUTOPULSE",
      "code_information": [
        {
          "code": "3502593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1266,
          "minimum": 265.86,
          "maximum": 926.9652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 648.8756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST X-LG LT 5001-10",
      "code_information": [
        {
          "code": "3502600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.1067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF C",
      "code_information": [
        {
          "code": "3502706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 547,
          "minimum": 114.87,
          "maximum": 400.5134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 280.3594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF D",
      "code_information": [
        {
          "code": "3502707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 475,
          "minimum": 99.75,
          "maximum": 347.795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 243.4565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-BUNNY W/FRAME & LINER",
      "code_information": [
        {
          "code": "3502709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 351,
          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 179.9015,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-LEG FULL SM 9128-01",
      "code_information": [
        {
          "code": "3502720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 345,
          "minimum": 72.45,
          "maximum": 252.609,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.8263,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3502751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMIN 46-62 13992000",
      "code_information": [
        {
          "code": "3503080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-HOOD ALL  0408-8xx-000",
      "code_information": [
        {
          "code": "3503348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 679,
          "minimum": 142.59,
          "maximum": 497.1638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 348.0147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ENV INFANT   8004-01",
      "code_information": [
        {
          "code": "3503370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT ARM",
      "code_information": [
        {
          "code": "3504148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT BOOT",
      "code_information": [
        {
          "code": "3504149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT FULL LENGTH",
      "code_information": [
        {
          "code": "3504150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.5299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED ARM",
      "code_information": [
        {
          "code": "3504151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED BOOT",
      "code_information": [
        {
          "code": "3504152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 12\\\" 13960000*",
      "code_information": [
        {
          "code": "3504230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.1788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER EYE        607120",
      "code_information": [
        {
          "code": "3504353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MAC 3&4",
      "code_information": [
        {
          "code": "3504355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MIL 2&3",
      "code_information": [
        {
          "code": "3504357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "3504552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.1678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1.5\\\" CT\\\"",
      "code_information": [
        {
          "code": "3504553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.1678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM      100 1974",
      "code_information": [
        {
          "code": "3504663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 326,
          "minimum": 68.46,
          "maximum": 238.6972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 167.088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM     12-7 1972",
      "code_information": [
        {
          "code": "3504665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CHANNELED         KVL03C",
      "code_information": [
        {
          "code": "3504905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST EZWALK XL 2001-05",
      "code_information": [
        {
          "code": "3505035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST STAT ALL 2001-00s",
      "code_information": [
        {
          "code": "3505545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA TENDERWRAP 4\\\"X10YDS",
      "code_information": [
        {
          "code": "3505570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WAFFLE  ALL SIZES    FW's",
      "code_information": [
        {
          "code": "3505575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.0237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2515H****",
      "code_information": [
        {
          "code": "3505815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.3042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICAL MED",
      "code_information": [
        {
          "code": "3505906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE HEAVY LARGE",
      "code_information": [
        {
          "code": "3505907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.7916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE CHILD   3004-12",
      "code_information": [
        {
          "code": "3505955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION ATEC",
      "code_information": [
        {
          "code": "3506118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3506181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-7FR \\\"SLIC\\\"       SC-14701",
      "code_information": [
        {
          "code": "3506470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CURITY ULTRAMER 6FR  6006",
      "code_information": [
        {
          "code": "3506758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 22G   383591",
      "code_information": [
        {
          "code": "3507108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 24G   383590",
      "code_information": [
        {
          "code": "3507111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW ARTERIAL VENOUS",
      "code_information": [
        {
          "code": "3507185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3W 16F 5CC  0119L16",
      "code_information": [
        {
          "code": "3507187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 30CC ALL 123600As",
      "code_information": [
        {
          "code": "3507190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 12 5 165812",
      "code_information": [
        {
          "code": "3507192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 14 5 165814",
      "code_information": [
        {
          "code": "3507193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 16 5 165816",
      "code_information": [
        {
          "code": "3507194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 18 5 165818",
      "code_information": [
        {
          "code": "3507195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 20 5 165820",
      "code_information": [
        {
          "code": "3507196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 22 5 165822",
      "code_information": [
        {
          "code": "3507197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 24 5 165824",
      "code_information": [
        {
          "code": "3507198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18F 0125RL18",
      "code_information": [
        {
          "code": "3507371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 260,
          "minimum": 54.6,
          "maximum": 190.372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 133.2604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 20F 30C W/V  0125RL20",
      "code_information": [
        {
          "code": "3507373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 22FR/30CC",
      "code_information": [
        {
          "code": "3507381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 24F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 134.798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 26F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 20FR 30CC      266720",
      "code_information": [
        {
          "code": "3507665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.8276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 24FR 30CC      266724",
      "code_information": [
        {
          "code": "3507670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3CC   8887603101",
      "code_information": [
        {
          "code": "3507688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W  8F  3CC   8887603085",
      "code_information": [
        {
          "code": "3507852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-OXIMETRY 5 LUMEN  5032805",
      "code_information": [
        {
          "code": "3508302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1222,
          "minimum": 256.62,
          "maximum": 894.7484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 626.3239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SOAKER 1\\\"           PM030",
      "code_information": [
        {
          "code": "3508888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 719,
          "minimum": 150.99,
          "maximum": 526.4518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 368.5163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-20X1.5 RADIO ARTE RA04220",
      "code_information": [
        {
          "code": "3509147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 16FR  010116",
      "code_information": [
        {
          "code": "3509269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 14FR  010114",
      "code_information": [
        {
          "code": "3509270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN STRAIGHT 18FR",
      "code_information": [
        {
          "code": "3509305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-CHEST DRAIN 9.6FR",
      "code_information": [
        {
          "code": "3509905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.7479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP ADJ     AA11",
      "code_information": [
        {
          "code": "3509911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.3685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-LOW TEMP ADJ      AA02",
      "code_information": [
        {
          "code": "3509912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3510001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.5331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COA 04273",
      "code_information": [
        {
          "code": "3510002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3510099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.4328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEX 72\\\"   DF47x-6121Z",
      "code_information": [
        {
          "code": "3510143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENTILATOR COAX",
      "code_information": [
        {
          "code": "3510148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLEANSER-BODY FOAMING REMEDY",
      "code_information": [
        {
          "code": "3510305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCLIP-MEDIUM         523800",
      "code_information": [
        {
          "code": "3510401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL SMALL 710-SMAL",
      "code_information": [
        {
          "code": "3510714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL MEDIUM 710-MED",
      "code_information": [
        {
          "code": "3510715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.6694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK PEDI-SELE",
      "code_information": [
        {
          "code": "3510817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL ALL SZ A11500x",
      "code_information": [
        {
          "code": "3510830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3511220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.6521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y PRISMAFLEX",
      "code_information": [
        {
          "code": "3511240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISP F/NEOBLUE COZY",
      "code_information": [
        {
          "code": "3511668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.6161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FOOT PNEU LRG PR  VP520L",
      "code_information": [
        {
          "code": "3511672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FT PNEU REGULAR PR VP520",
      "code_information": [
        {
          "code": "3511673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE LTX-FREE   610-002",
      "code_information": [
        {
          "code": "3511677",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-YOUTH LF/ALUM      7702",
      "code_information": [
        {
          "code": "3511795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3511958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 155.8122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB TALL",
      "code_information": [
        {
          "code": "3511962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 155.8122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-WAFFLE 16x16x2  200WCI",
      "code_information": [
        {
          "code": "3512318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FOAM W/COVER    154264",
      "code_information": [
        {
          "code": "3512506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 211,
          "minimum": 44.31,
          "maximum": 154.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 108.1459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 16-18FR",
      "code_information": [
        {
          "code": "3512575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.3935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.1CM 9231",
      "code_information": [
        {
          "code": "3512760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.2CM 9232",
      "code_information": [
        {
          "code": "3512761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.1427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ANCHOR PICC LNE PIC0220",
      "code_information": [
        {
          "code": "3512770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 PED PEDI CAP",
      "code_information": [
        {
          "code": "3512773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.6694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RESQPOD 029-12-0242-000",
      "code_information": [
        {
          "code": "3512775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 666.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FEMOSTOP         11165",
      "code_information": [
        {
          "code": "3512782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 668.8647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH STABILIZ    DIO120",
      "code_information": [
        {
          "code": "3512792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH SECURMENT VPPDFP",
      "code_information": [
        {
          "code": "3512794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL  SMALL  S-22MM",
      "code_information": [
        {
          "code": "3513121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.3685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL MEDIUM  M-29MM",
      "code_information": [
        {
          "code": "3513123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.5942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-ACCU ANTI-REFLUX INS8401",
      "code_information": [
        {
          "code": "3513202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1657,
          "minimum": 347.97,
          "maximum": 1213.2554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 849.2788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST VALVE PNEUMOSTAT",
      "code_information": [
        {
          "code": "3513225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.8655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT PRATT        SU130s",
      "code_information": [
        {
          "code": "3513231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE W/ISO BAG    1003",
      "code_information": [
        {
          "code": "3513475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.2399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM SM SIMP CS",
      "code_information": [
        {
          "code": "3514025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 414,
          "minimum": 86.94,
          "maximum": 303.1308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.1916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM BRIDGE",
      "code_information": [
        {
          "code": "3514230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 640,
          "minimum": 134.4,
          "maximum": 468.608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 328.0256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-PREVENA 45ML",
      "code_information": [
        {
          "code": "3514251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 367,
          "minimum": 77.07,
          "maximum": 268.7174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 188.1022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC 500ML WITH GEL",
      "code_information": [
        {
          "code": "3514255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 211.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO MED",
      "code_information": [
        {
          "code": "3514259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1213,
          "minimum": 254.73,
          "maximum": 888.1586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 621.711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO SM",
      "code_information": [
        {
          "code": "3514261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYME 4X4 5044",
      "code_information": [
        {
          "code": "3514264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM     10X15CM",
      "code_information": [
        {
          "code": "3514272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5FR   006173P",
      "code_information": [
        {
          "code": "3514812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1649,
          "minimum": 346.29,
          "maximum": 1207.3978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 845.1785,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-REDIPAK",
      "code_information": [
        {
          "code": "3514819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLOOD        SQ40S",
      "code_information": [
        {
          "code": "3516138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTERLINE-INTUBATED SET 185",
      "code_information": [
        {
          "code": "3516160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-MR 9GX14CM 20MM",
      "code_information": [
        {
          "code": "3518855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2344,
          "minimum": 492.24,
          "maximum": 1716.2768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1201.3938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX16CM",
      "code_information": [
        {
          "code": "3518857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 293.6854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX1xCM",
      "code_information": [
        {
          "code": "3518865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 293.6854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX1xCM",
      "code_information": [
        {
          "code": "3518868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX10CM",
      "code_information": [
        {
          "code": "3518870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 578,
          "minimum": 121.38,
          "maximum": 423.2116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 296.2481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-LARYNGOSCOPE DISP",
      "code_information": [
        {
          "code": "3518940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1962",
      "code_information": [
        {
          "code": "3519300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1034,
          "minimum": 217.14,
          "maximum": 757.0948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 529.9664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS LF ADLT",
      "code_information": [
        {
          "code": "3519395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.0534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUGGER-HEART STERNUM ALL 1000s",
      "code_information": [
        {
          "code": "3519770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 12F 36\\\"",
      "code_information": [
        {
          "code": "3520193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 20F 5CC",
      "code_information": [
        {
          "code": "3520196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 78.9312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 22FR 20CC",
      "code_information": [
        {
          "code": "3520199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 119.4218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INHALER-DIAMOND SPACR 107-9830",
      "code_information": [
        {
          "code": "3520701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-INTUBATION ALL Gs",
      "code_information": [
        {
          "code": "3521014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1015,
          "minimum": 213.15,
          "maximum": 743.183,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 520.2281,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ALGO HEARING TEST  040546",
      "code_information": [
        {
          "code": "3521438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BARRIER MINOR PROTECTIVE",
      "code_information": [
        {
          "code": "3521441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT FEMORAL 111644",
      "code_information": [
        {
          "code": "3521442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACOSTOMY PROC ******",
      "code_information": [
        {
          "code": "3521523",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 207,
          "minimum": 43.47,
          "maximum": 151.5654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 106.0958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH CVP SL       AK-24301",
      "code_information": [
        {
          "code": "3521655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRAINAL ACCESS    INS-5HND",
      "code_information": [
        {
          "code": "3521683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2054,
          "minimum": 431.34,
          "maximum": 1503.9388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1052.7572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DAILY CARE            6638",
      "code_information": [
        {
          "code": "3521745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAINAGE PLEURX    50-7510",
      "code_information": [
        {
          "code": "3521755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 422.333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HYPOTHERMIA \\\"KOOL KIT\\\" 900",
      "code_information": [
        {
          "code": "3521917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1792,
          "minimum": 376.32,
          "maximum": 1312.1024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 918.4717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 6FR AK-09601***",
      "code_information": [
        {
          "code": "3521942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 407,
          "minimum": 85.47,
          "maximum": 298.0054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 208.6038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 8.5 AK-09803CDC",
      "code_information": [
        {
          "code": "3521947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 628,
          "minimum": 131.88,
          "maximum": 459.8216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 321.8751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGAT CONE/TUBE BX  7721",
      "code_information": [
        {
          "code": "3521963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-SARAH 2778 ALL SIZES",
      "code_information": [
        {
          "code": "3522000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 505,
          "minimum": 106.05,
          "maximum": 369.761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 258.8327,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-HANNAH 2160 ALL SIZES",
      "code_information": [
        {
          "code": "3522002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 256,
          "minimum": 53.76,
          "maximum": 187.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.2102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K ALL SIZES",
      "code_information": [
        {
          "code": "3522003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 147.6115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LUMBAR PUNCTURE    4011015",
      "code_information": [
        {
          "code": "3522152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.3607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MAC CATH MULTI AK-21242CDC",
      "code_information": [
        {
          "code": "3522182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1364,
          "minimum": 286.44,
          "maximum": 998.7208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.1046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 20FR         6820",
      "code_information": [
        {
          "code": "3522270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 361.8532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00568241",
      "code_information": [
        {
          "code": "3522271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 361.8532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KOOL NEONATAL 950",
      "code_information": [
        {
          "code": "3522460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1169,
          "minimum": 245.49,
          "maximum": 855.9418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 599.1593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING ALL",
      "code_information": [
        {
          "code": "3522465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-MORGAN LTX-FREE    MT2000",
      "code_information": [
        {
          "code": "3522687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 448,
          "minimum": 94.08,
          "maximum": 328.0256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 229.6179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-4-WAY         4238701",
      "code_information": [
        {
          "code": "3523121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND PREMATURE 900643",
      "code_information": [
        {
          "code": "3523139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND MICRO     900644",
      "code_information": [
        {
          "code": "3523140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 50MM    RD805-10",
      "code_information": [
        {
          "code": "3523187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 101,
          "minimum": 21.21,
          "maximum": 73.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.7665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MITT-HAND CONTROL PR  M2023V-A",
      "code_information": [
        {
          "code": "3523675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTRAOSSEOUS ORANGE",
      "code_information": [
        {
          "code": "3523854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATN     ALL 7700's",
      "code_information": [
        {
          "code": "3523864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX11C",
      "code_information": [
        {
          "code": "3525447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X13.8 C1616A",
      "code_information": [
        {
          "code": "3525465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.7479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X7.8  C1610A",
      "code_information": [
        {
          "code": "3525466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X7.8  C2010A",
      "code_information": [
        {
          "code": "3525467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "3525468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL STR 17GX4-1/2\\\"",
      "code_information": [
        {
          "code": "3525873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 20G X 1\\\"",
      "code_information": [
        {
          "code": "3525882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.1678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS G04153",
      "code_information": [
        {
          "code": "3525915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 857,
          "minimum": 179.97,
          "maximum": 627.4954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 439.2468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-4   DJ4011X",
      "code_information": [
        {
          "code": "3525924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 125.5723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL PENCAN    333866",
      "code_information": [
        {
          "code": "3525950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX5\\\"    405148",
      "code_information": [
        {
          "code": "3525951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.5299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX7\\\"    405149",
      "code_information": [
        {
          "code": "3525960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X22G",
      "code_information": [
        {
          "code": "3525975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.7916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X25G",
      "code_information": [
        {
          "code": "3525976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PROBLOC 20X100 HN3S-100",
      "code_information": [
        {
          "code": "3526110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E CATH PLUS 241285-41E",
      "code_information": [
        {
          "code": "3526122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 467,
          "minimum": 98.07,
          "maximum": 341.9374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 239.3562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POLYLOOP-LIGATING DEVICE HX-40",
      "code_information": [
        {
          "code": "3526123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 495.1136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PULSAVAC 00-5150-182-00",
      "code_information": [
        {
          "code": "3526127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL EXTEND 480422",
      "code_information": [
        {
          "code": "3526149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3703,
          "minimum": 777.63,
          "maximum": 2711.3366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1897.9356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-AIRWAY EMMA 17448",
      "code_information": [
        {
          "code": "3526175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.0816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.5/2.8",
      "code_information": [
        {
          "code": "3526179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1520,
          "minimum": 319.2,
          "maximum": 1112.944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 779.0608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO xxXxxMM 2.0",
      "code_information": [
        {
          "code": "3526182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.9914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 5800-8-125",
      "code_information": [
        {
          "code": "3526187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1120,
          "minimum": 235.2,
          "maximum": 820.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 574.0448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.3MM TWIST QC",
      "code_information": [
        {
          "code": "3526189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT,-NIFOMETER 10-340-03",
      "code_information": [
        {
          "code": "3526194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-NASAL AUTOMATION MAD300",
      "code_information": [
        {
          "code": "3526195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.4296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 70143061",
      "code_information": [
        {
          "code": "3526216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 95.3324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT BUTTERFLY 240073",
      "code_information": [
        {
          "code": "3526217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER SB4000SA",
      "code_information": [
        {
          "code": "3526218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1162,
          "minimum": 244.02,
          "maximum": 850.8164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 595.5715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SB4040SC",
      "code_information": [
        {
          "code": "3526219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 665.2769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MALLEABLE MS4000SC",
      "code_information": [
        {
          "code": "3526220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1330,
          "minimum": 279.3,
          "maximum": 973.826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 681.6782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y936H",
      "code_information": [
        {
          "code": "3526223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CANNULATED 2.0X120MM",
      "code_information": [
        {
          "code": "3526239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1136,
          "minimum": 238.56,
          "maximum": 831.7792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 582.2454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICYRL-4-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X36",
      "code_information": [
        {
          "code": "3526256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X96",
      "code_information": [
        {
          "code": "3526257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-0 PDS PLUS 1X60",
      "code_information": [
        {
          "code": "3526258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 12X18",
      "code_information": [
        {
          "code": "3526259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-4-0 PLUS 1X18",
      "code_information": [
        {
          "code": "3526264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRILL 2.0 SPEED HAND WRIS",
      "code_information": [
        {
          "code": "3526271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1433.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM   70890830",
      "code_information": [
        {
          "code": "3526275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM ANTERIOR",
      "code_information": [
        {
          "code": "3526278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 595,
          "minimum": 124.95,
          "maximum": 435.659,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 304.9613,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM     70890832",
      "code_information": [
        {
          "code": "3526280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 119,
          "minimum": 24.99,
          "maximum": 87.1318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 60.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT LMA ALL SIZE",
      "code_information": [
        {
          "code": "3526297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURAGAIN SIZE 4",
      "code_information": [
        {
          "code": "3526298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREADED AR-13226T",
      "code_information": [
        {
          "code": "3526314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 930,
          "minimum": 195.3,
          "maximum": 680.946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 476.6622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BATTERY 1.5 50-1010",
      "code_information": [
        {
          "code": "3526343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 919,
          "minimum": 192.99,
          "maximum": 672.8918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 471.0243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL EPISTAX 10CM",
      "code_information": [
        {
          "code": "3526349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 240.3813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC SUPER AK-24301-SK",
      "code_information": [
        {
          "code": "3526356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 684,
          "minimum": 143.64,
          "maximum": 500.8248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 350.5774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY 351-3500SZ",
      "code_information": [
        {
          "code": "3526357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 946,
          "minimum": 198.66,
          "maximum": 692.6612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 484.8628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 115” Y 1637101",
      "code_information": [
        {
          "code": "3526361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LITHOTOMY DYNJ31774G",
      "code_information": [
        {
          "code": "3526362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 789,
          "minimum": 165.69,
          "maximum": 577.7058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 404.3941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER CLOSED 4MM STRT",
      "code_information": [
        {
          "code": "3526366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1269,
          "minimum": 266.49,
          "maximum": 929.1618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 650.4133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAL, X",
      "code_information": [
        {
          "code": "3526388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 528,
          "minimum": 110.88,
          "maximum": 386.6016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 270.6211,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPTIFLOW JR 2 NASAl LG",
      "code_information": [
        {
          "code": "3526389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 528,
          "minimum": 110.88,
          "maximum": 386.6016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 270.6211,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-METATRSAL 20MM",
      "code_information": [
        {
          "code": "3526404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.2X1.8X87MM",
      "code_information": [
        {
          "code": "3526414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CANN 2.2 A-2716",
      "code_information": [
        {
          "code": "3526415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2846,
          "minimum": 597.66,
          "maximum": 2083.8412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1458.6888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 20GX6 405211",
      "code_information": [
        {
          "code": "3526416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL 7 SP-78107",
      "code_information": [
        {
          "code": "3526419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1023,
          "minimum": 214.83,
          "maximum": 749.0406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 524.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BASIC BREAST DYNJ60139",
      "code_information": [
        {
          "code": "3526420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 604.7972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-GEN VASCULAR DYNJ60177",
      "code_information": [
        {
          "code": "3526422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1556,
          "minimum": 326.76,
          "maximum": 1139.3032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 797.5122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC SIE DYNJ905699",
      "code_information": [
        {
          "code": "3526423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1952,
          "minimum": 409.92,
          "maximum": 1429.2544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1000.4781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO SHOULDER DYNJ60141",
      "code_information": [
        {
          "code": "3526425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 393.1182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO KNEE DYNJ60140",
      "code_information": [
        {
          "code": "3526428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 314.6996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-LOW FLOW,DISP PATIENT",
      "code_information": [
        {
          "code": "3526443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 514.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HIGH FLOW, DISP PT'",
      "code_information": [
        {
          "code": "3526445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1053,
          "minimum": 221.13,
          "maximum": 771.0066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 539.7046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SMALL PED NASAL OXYGEN",
      "code_information": [
        {
          "code": "3526446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.29,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-PED/ADULT SM – MP1500",
      "code_information": [
        {
          "code": "3526447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.29,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIGH FLOW ADULT MA1700",
      "code_information": [
        {
          "code": "3526449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INFANT OVER THE EAR",
      "code_information": [
        {
          "code": "3526455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORPEDO-4.0MM X13 CM AR-8400T",
      "code_information": [
        {
          "code": "3526458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 930,
          "minimum": 195.3,
          "maximum": 680.946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 476.6622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ABLATOR-ASPIRATING AR-8921",
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        {
          "code": "3526459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.0293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR COLD 10MM Rnd",
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        {
          "code": "3526467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.0237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-OVAL FLUSH-CUT AR-8550FOS",
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        {
          "code": "3526471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 403.8815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOLVE-CUT RESIST XL520036000",
      "code_information": [
        {
          "code": "3526473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 422.333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE/BLACK 1.5MM",
      "code_information": [
        {
          "code": "3526474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-90 DEG APOLLO AR-9811",
      "code_information": [
        {
          "code": "3526476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.0293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELITE IRRIG 5407010470",
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        {
          "code": "3526484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 397.731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRING-MR EMPOWERCTA",
      "code_information": [
        {
          "code": "3526487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.0707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 12 DPSB 60707010200",
      "code_information": [
        {
          "code": "3526492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 145.0488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPSB 60707010300",
      "code_information": [
        {
          "code": "3526493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPSB 60707010400",
      "code_information": [
        {
          "code": "3526494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.3639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPDB 60708010300",
      "code_information": [
        {
          "code": "3526495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 240.3813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TUBING MXB-T",
      "code_information": [
        {
          "code": "3526520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 506,
          "minimum": 106.26,
          "maximum": 370.4932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 259.3452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-FLOTRAX PERFUSION 84\\\" M",
      "code_information": [
        {
          "code": "3526525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2947,
          "minimum": 618.87,
          "maximum": 2157.7934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1510.4554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT YG-272T",
      "code_information": [
        {
          "code": "3526528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.5MMX13CM AR-8550EX",
      "code_information": [
        {
          "code": "3526571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 232.6932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BULLET CUTTING 3MM",
      "code_information": [
        {
          "code": "3526591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2519,
          "minimum": 528.99,
          "maximum": 1844.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1291.0883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MAJOR HEAD/NEC DYNJ38985A",
      "code_information": [
        {
          "code": "3526665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 696,
          "minimum": 146.16,
          "maximum": 509.6112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 356.7278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MINOR HEAD/NECK",
      "code_information": [
        {
          "code": "3526670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 377,
          "minimum": 79.17,
          "maximum": 276.0394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 193.2276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-BIOPATCH CHG 1”X4MM 4150",
      "code_information": [
        {
          "code": "3526904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-JAW TISSUE ENSEAL LRG",
      "code_information": [
        {
          "code": "3526926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2829,
          "minimum": 594.09,
          "maximum": 2071.3938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1449.9757,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT SMALL",
      "code_information": [
        {
          "code": "3526929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 571,
          "minimum": 119.91,
          "maximum": 418.0862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 292.6603,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT LARGE",
      "code_information": [
        {
          "code": "3526930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 660,
          "minimum": 138.6,
          "maximum": 483.252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 338.2764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A443",
      "code_information": [
        {
          "code": "3526935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 201.4282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A445",
      "code_information": [
        {
          "code": "3526936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.8655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFX 2-0 SXMP1B413",
      "code_information": [
        {
          "code": "3526938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 352,
          "minimum": 73.92,
          "maximum": 257.7344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 180.4141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4FUSION 2.0 CALIBRATED",
      "code_information": [
        {
          "code": "3526943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1113,
          "minimum": 233.73,
          "maximum": 814.9386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 570.457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-AFFINITY MANIFOLD 1S85R1",
      "code_information": [
        {
          "code": "3526965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COMP SPEEDARC 11X15X13MM",
      "code_information": [
        {
          "code": "3526978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5134,
          "minimum": 1078.14,
          "maximum": 3759.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2631.3804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7.5CM POST",
      "code_information": [
        {
          "code": "3526995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 608,
          "minimum": 127.68,
          "maximum": 445.1776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 311.6243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING DISP EXT 5450850003",
      "code_information": [
        {
          "code": "3526996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1879,
          "minimum": 394.59,
          "maximum": 1375.8038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 963.0627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINDER-DISP SUCT CAN",
      "code_information": [
        {
          "code": "3526997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIAMETER-STRAIGHT 5450800309",
      "code_information": [
        {
          "code": "3526999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3756,
          "minimum": 788.76,
          "maximum": 2750.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1925.1002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRICOTHYROIDOTOMY EMERGENT",
      "code_information": [
        {
          "code": "3527020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1028,
          "minimum": 215.88,
          "maximum": 752.7016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 526.8911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-2.7MM 311.26",
      "code_information": [
        {
          "code": "3527056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 864,
          "minimum": 181.44,
          "maximum": 632.6208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 442.8346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.15, 1.5MM",
      "code_information": [
        {
          "code": "3527057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.3831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.19, 2.0MM",
      "code_information": [
        {
          "code": "3527058",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 849,
          "minimum": 178.29,
          "maximum": 621.6378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 435.1465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SUCTION 12.7 HI CAPACITY",
      "code_information": [
        {
          "code": "3527060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X .75”",
      "code_information": [
        {
          "code": "3527066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.1678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.35X50X101MM",
      "code_information": [
        {
          "code": "3527084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.9914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-BIOPSY MARQUEE",
      "code_information": [
        {
          "code": "3527097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 399.2687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PICK-VEIN 6541",
      "code_information": [
        {
          "code": "3527102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.0/2.3",
      "code_information": [
        {
          "code": "3527119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1520,
          "minimum": 319.2,
          "maximum": 1112.944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 779.0608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO",
      "code_information": [
        {
          "code": "3527121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.9914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BRUSH ALGER 0.5MM",
      "code_information": [
        {
          "code": "3527123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.7164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOPATCH-DRESS CHG 1” X 7MM",
      "code_information": [
        {
          "code": "3527124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLENOID DRILL 2.5MM",
      "code_information": [
        {
          "code": "3527142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8074,
          "minimum": 1695.54,
          "maximum": 5911.7828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4138.248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD WIDE MT-APUW",
      "code_information": [
        {
          "code": "3527145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLUS-VIVAER ARC DISP CAT500",
      "code_information": [
        {
          "code": "3527147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9026,
          "minimum": 1895.46,
          "maximum": 6608.8372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4626.186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-KEITH FREE 1827-2.5DC",
      "code_information": [
        {
          "code": "3527159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3MM AR-8930D-13",
      "code_information": [
        {
          "code": "3527163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-GONIO SURG OSIG",
      "code_information": [
        {
          "code": "3527169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 3.2X125MM GRAY",
      "code_information": [
        {
          "code": "3527179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1195,
          "minimum": 250.95,
          "maximum": 874.979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 612.4853,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-POSEY SECURE INFANT PED",
      "code_information": [
        {
          "code": "3527200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 199.3781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-INDIGO 140CM CATRXKIT",
      "code_information": [
        {
          "code": "3527201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4163.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPERATOR-C4 PENUMBRA SEPC4",
      "code_information": [
        {
          "code": "3527202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4654,
          "minimum": 977.34,
          "maximum": 3407.6588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2385.3612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENGINE INDIGO IAPS3",
      "code_information": [
        {
          "code": "3527203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1238.2966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VPEP 510",
      "code_information": [
        {
          "code": "3527204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 238.8436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRVO2-TUBE CHAMBER KIT, 900PT",
      "code_information": [
        {
          "code": "3527205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 730,
          "minimum": 153.3,
          "maximum": 534.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 374.1542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN W/AO 5.0MM",
      "code_information": [
        {
          "code": "3527232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 250.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-QUICK CONN DRVR-UQC-T10",
      "code_information": [
        {
          "code": "3527241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1399,
          "minimum": 293.79,
          "maximum": 1024.3478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 717.0435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7X70MM IJS-CDC-2770",
      "code_information": [
        {
          "code": "3527242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1427.4239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERES-PASSIVE 8801075",
      "code_information": [
        {
          "code": "3527246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.9X10X61MM",
      "code_information": [
        {
          "code": "3527253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.9914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DRILL SELF HOLD",
      "code_information": [
        {
          "code": "3527257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2110,
          "minimum": 443.1,
          "maximum": 1544.942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1081.4594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE 108984",
      "code_information": [
        {
          "code": "3527264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO MICRO 0",
      "code_information": [
        {
          "code": "3527266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 332.6385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3527268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5424,
          "minimum": 1139.04,
          "maximum": 3971.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2780.017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-STERILE PGH 396985",
      "code_information": [
        {
          "code": "3527269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-BS IS-1 330834",
      "code_information": [
        {
          "code": "3527270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 7MM, 70X",
      "code_information": [
        {
          "code": "3527281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 362.3658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-301-CG 343586",
      "code_information": [
        {
          "code": "3527282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIDER TS101DC",
      "code_information": [
        {
          "code": "3527287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 594,
          "minimum": 124.74,
          "maximum": 434.9268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 304.4488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM 7089-0832",
      "code_information": [
        {
          "code": "3527289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.8919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 1.27MM",
      "code_information": [
        {
          "code": "3527290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER DS2C026",
      "code_information": [
        {
          "code": "3527342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4316,
          "minimum": 906.36,
          "maximum": 3160.1752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2212.1226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ALLEN 3.0MM 904-0030",
      "code_information": [
        {
          "code": "3527343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 375,
          "minimum": 78.75,
          "maximum": 274.575,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 192.2025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3527395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAXI-THERM LITE 871*******",
      "code_information": [
        {
          "code": "3527520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-CALAZIME REMEDY 4 OZ",
      "code_information": [
        {
          "code": "3527567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-K SOFT 117464",
      "code_information": [
        {
          "code": "3527806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 60-S FIRM 119291",
      "code_information": [
        {
          "code": "3527807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-C MEDIUM 342657",
      "code_information": [
        {
          "code": "3527808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-INFANT POSITIONER",
      "code_information": [
        {
          "code": "3527875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.9704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CRM DYNJ62070",
      "code_information": [
        {
          "code": "3527887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 756,
          "minimum": 158.76,
          "maximum": 553.5432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 387.4802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-INFANT FULL BODY",
      "code_information": [
        {
          "code": "3527890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1059,
          "minimum": 222.39,
          "maximum": 775.3998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 542.7799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNCK SLCT980010",
      "code_information": [
        {
          "code": "3527947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-IRR SUCT 5500-573-000",
      "code_information": [
        {
          "code": "3527977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3127,
          "minimum": 656.67,
          "maximum": 2289.5894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1602.7126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION 5450-851-012",
      "code_information": [
        {
          "code": "3527978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MICRO-IQ 12CM 5500-25S-309",
      "code_information": [
        {
          "code": "3527979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5094,
          "minimum": 1069.74,
          "maximum": 3729.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2610.8788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STD-12CM 5500-25S-307",
      "code_information": [
        {
          "code": "3527980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4754,
          "minimum": 998.34,
          "maximum": 3480.8788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2436.6152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRACUDA-12CM IQ 5500-25S-310",
      "code_information": [
        {
          "code": "3527981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5201,
          "minimum": 1092.21,
          "maximum": 3808.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2665.7205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND ROYLAN RT MED",
      "code_information": [
        {
          "code": "3528086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORTHOSIS-ANKLE FOOT LG",
      "code_information": [
        {
          "code": "3528101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 704,
          "minimum": 147.84,
          "maximum": 515.4688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 360.8282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 30 DPSB 60707010500",
      "code_information": [
        {
          "code": "3529495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 190.6649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPDB 60708010200",
      "code_information": [
        {
          "code": "3529498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 428,
          "minimum": 89.88,
          "maximum": 313.3816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 219.3671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SINGLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 326.488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST DOUBLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 468,
          "minimum": 98.28,
          "maximum": 342.6696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 239.8687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #4     4DCP",
      "code_information": [
        {
          "code": "3533309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #6,8,10 DCP",
      "code_information": [
        {
          "code": "3533315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SKIN TEMP DISP MU11228",
      "code_information": [
        {
          "code": "3533577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.4328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP ISOLETTE    MU12551",
      "code_information": [
        {
          "code": "3533578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-RECTAL/ESOPH ST     491B",
      "code_information": [
        {
          "code": "3533590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTANT-SKIN REMEDY 2 OZ",
      "code_information": [
        {
          "code": "3536085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-SKIN NO STING    MSC1528",
      "code_information": [
        {
          "code": "3536099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.7807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-EYE FOAM       28300",
      "code_information": [
        {
          "code": "3536100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-JP 100ML  SU130-1305",
      "code_information": [
        {
          "code": "3538200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3539345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INITIATION BREAST MILK 673",
      "code_information": [
        {
          "code": "3539346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 356,
          "minimum": 74.76,
          "maximum": 260.6632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 182.4642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-MANUAL HARMONY 67186S",
      "code_information": [
        {
          "code": "3539347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-BIS QUATTRO    186-0106",
      "code_information": [
        {
          "code": "3541300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 336,
          "minimum": 70.56,
          "maximum": 246.0192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 172.2134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS PED DISP",
      "code_information": [
        {
          "code": "3541324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.3183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS ADLT DISP",
      "code_information": [
        {
          "code": "3541325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.3183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SKIN HNICU38",
      "code_information": [
        {
          "code": "3541328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.6772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-ACOUSTIC RESPIRATION",
      "code_information": [
        {
          "code": "3541329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 172.726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RECIP PLATELET     4C-2100",
      "code_information": [
        {
          "code": "3541430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD FILTRATION   4020005",
      "code_information": [
        {
          "code": "3541446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.8559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BURETROL 150ML",
      "code_information": [
        {
          "code": "3541503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 252,
          "minimum": 52.92,
          "maximum": 184.5144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.1601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW RADIAL ARTERY",
      "code_information": [
        {
          "code": "3541912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP Y FOR BLOOD IV  D-100",
      "code_information": [
        {
          "code": "3541945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 436.6841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DIALYZER EXELTRA    5M2119",
      "code_information": [
        {
          "code": "3541947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 292,
          "minimum": 61.32,
          "maximum": 213.8024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 149.6617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3541950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1539,
          "minimum": 323.19,
          "maximum": 1126.8558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 788.7991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FEMORAL ART  C-PMS-401J-FA",
      "code_information": [
        {
          "code": "3542127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO ALL SZ W/ STABILIZER",
      "code_information": [
        {
          "code": "3542128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1489,
          "minimum": 312.69,
          "maximum": 1090.2458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 763.1721,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER HF 1000 PRISMAFLEX",
      "code_information": [
        {
          "code": "3542131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2248,
          "minimum": 472.08,
          "maximum": 1645.9856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1152.1899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION OSTOMY BX 1500H",
      "code_information": [
        {
          "code": "3542454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 110 INFUSION 1635101",
      "code_information": [
        {
          "code": "3542760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRISMAFLEX TPE2000 114093",
      "code_information": [
        {
          "code": "3542806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2271,
          "minimum": 476.91,
          "maximum": 1662.8262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1163.9783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RADIAL ARTERY C-PMS-301-RA",
      "code_information": [
        {
          "code": "3543008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORACENTESIS      4653-48",
      "code_information": [
        {
          "code": "3543530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TUR IRRIGATION  06543-01",
      "code_information": [
        {
          "code": "3543551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE REPOSITION",
      "code_information": [
        {
          "code": "3543681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 497,
          "minimum": 104.37,
          "maximum": 363.9034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 254.7324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE XL REPOSITION",
      "code_information": [
        {
          "code": "3543685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 405.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE SM   2042-01",
      "code_information": [
        {
          "code": "3543730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE LRG  2042-03",
      "code_information": [
        {
          "code": "3543732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-NIPPLE REGULAR   67203S",
      "code_information": [
        {
          "code": "3544003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SEQ COMP KNEE      95xx",
      "code_information": [
        {
          "code": "3544619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 106.6083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501B",
      "code_information": [
        {
          "code": "3544638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.5832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501L",
      "code_information": [
        {
          "code": "3544639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.5942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE   VP501M",
      "code_information": [
        {
          "code": "3544640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.8559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530M",
      "code_information": [
        {
          "code": "3544645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.5832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530L",
      "code_information": [
        {
          "code": "3544650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM CHILD        8001-01",
      "code_information": [
        {
          "code": "3544659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ELEVATOR     8011-02",
      "code_information": [
        {
          "code": "3544860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.1067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE ALL SZS TX4442-0x",
      "code_information": [
        {
          "code": "3545160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE PED       9007-00",
      "code_information": [
        {
          "code": "3545177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 3L   5B9858",
      "code_information": [
        {
          "code": "3545500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 539,
          "minimum": 113.19,
          "maximum": 394.6558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 276.2591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 3L  5B9859",
      "code_information": [
        {
          "code": "3545502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 557,
          "minimum": 116.97,
          "maximum": 407.8354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 285.4848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 2L  5B9896",
      "code_information": [
        {
          "code": "3545504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 256.7825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 2L   5B9876",
      "code_information": [
        {
          "code": "3545505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 228.0803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIAL 1.5% 3L       5B9857",
      "code_information": [
        {
          "code": "3545515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 529,
          "minimum": 111.09,
          "maximum": 387.3338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 271.1337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 1000ML  07139-09",
      "code_information": [
        {
          "code": "3545555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-SW IRRIG 2000ML  07973-07",
      "code_information": [
        {
          "code": "3545613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.7086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-GYLCINE 1.5% IRRIG 3000ML",
      "code_information": [
        {
          "code": "3545747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.5832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML  07972-08",
      "code_information": [
        {
          "code": "3545751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.1209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 3000ML 07828-08",
      "code_information": [
        {
          "code": "3545752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.1209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML R5200-01",
      "code_information": [
        {
          "code": "3545753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 1000ML 07953-09",
      "code_information": [
        {
          "code": "3545755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-MDI ADAPTER INLINE",
      "code_information": [
        {
          "code": "3545901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.0MM 2883-02-040",
      "code_information": [
        {
          "code": "3547925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2602.1656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-BENDING 03.501.072",
      "code_information": [
        {
          "code": "3547929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1032,
          "minimum": 216.72,
          "maximum": 755.6304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 528.9413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 650.010",
      "code_information": [
        {
          "code": "3547941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM 60XL",
      "code_information": [
        {
          "code": "3547946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 346.477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIXER-CEMENT 3CC 658.969S",
      "code_information": [
        {
          "code": "3547948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.601S",
      "code_information": [
        {
          "code": "3547949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ULTRA ACCESS 658.902S",
      "code_information": [
        {
          "code": "3547952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5359,
          "minimum": 1125.39,
          "maximum": 3923.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2746.7019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC M6275009/10",
      "code_information": [
        {
          "code": "3547958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.5299,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-QUILL 2-0 YA-2034Q",
      "code_information": [
        {
          "code": "3547961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 336,
          "minimum": 70.56,
          "maximum": 246.0192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 172.2134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-4-0 PROLENE 8526H",
      "code_information": [
        {
          "code": "3547969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT",
      "code_information": [
        {
          "code": "3547970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 346.477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX",
      "code_information": [
        {
          "code": "3547971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 398,
          "minimum": 83.58,
          "maximum": 291.4156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 203.9909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY UNCUFF",
      "code_information": [
        {
          "code": "3547972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 295.223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 2MM AR-7523",
      "code_information": [
        {
          "code": "3547986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-ZONE NAVIGATOR AR-7900",
      "code_information": [
        {
          "code": "3547987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 650.112",
      "code_information": [
        {
          "code": "3547990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX CN",
      "code_information": [
        {
          "code": "3547997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 250.1195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX UN",
      "code_information": [
        {
          "code": "3547998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 402,
          "minimum": 84.42,
          "maximum": 294.3444,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 206.0411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SHILEY",
      "code_information": [
        {
          "code": "3547999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY CUFFED",
      "code_information": [
        {
          "code": "3548000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 671,
          "minimum": 140.91,
          "maximum": 491.3062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 343.9143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED  4LPC",
      "code_information": [
        {
          "code": "3548001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 626,
          "minimum": 131.46,
          "maximum": 458.3572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 320.85,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ4 S",
      "code_information": [
        {
          "code": "3548003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.0173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-TRACH 15MM DECANN WHITE",
      "code_information": [
        {
          "code": "3548004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-TRACH SZ 1 DECANN SH",
      "code_information": [
        {
          "code": "3548005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED",
      "code_information": [
        {
          "code": "3548006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 780,
          "minimum": 163.8,
          "maximum": 571.116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 399.7812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY FLEX INNER",
      "code_information": [
        {
          "code": "3548007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ1",
      "code_information": [
        {
          "code": "3548009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 62.0173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FLUENT DISP FLT-112",
      "code_information": [
        {
          "code": "3548028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1739,
          "minimum": 365.19,
          "maximum": 1273.2958,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 891.3071,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MOMOPTY 20X15 21201",
      "code_information": [
        {
          "code": "3549005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 458,
          "minimum": 96.18,
          "maximum": 335.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 234.7433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEELIFT-AFO  081531532",
      "code_information": [
        {
          "code": "3549018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 842,
          "minimum": 176.82,
          "maximum": 616.5124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 431.5587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-SUCTION NEURO NST031/25",
      "code_information": [
        {
          "code": "3549020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-SHANK MOD 5",
      "code_information": [
        {
          "code": "3549027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-LORDOTIC 5",
      "code_information": [
        {
          "code": "3549030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1203.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KVLAB3C",
      "code_information": [
        {
          "code": "3549037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.5189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KCLAB2C",
      "code_information": [
        {
          "code": "3549038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.7948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPEN 279726500",
      "code_information": [
        {
          "code": "3549047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3029,
          "minimum": 636.09,
          "maximum": 2217.8338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1552.4837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX ER VALVE REPLACEMEN",
      "code_information": [
        {
          "code": "3549059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX CATH ACCESS 50-7280",
      "code_information": [
        {
          "code": "3549060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.5755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-NAVIGATION 286750210S",
      "code_information": [
        {
          "code": "3549063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1376.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 020 XFR004xxx",
      "code_information": [
        {
          "code": "3549066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2903,
          "minimum": 609.63,
          "maximum": 2125.5766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1487.9036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL SND1T3 20.5",
      "code_information": [
        {
          "code": "3549069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2587.8145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-SYNC DISTAL RADIAL, SDRB-",
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        {
          "code": "3549082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 208.0912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-BASIC HEEL PRESSURE",
      "code_information": [
        {
          "code": "3549107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 172.726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- LIGHT 03.612.021S",
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        {
          "code": "3549135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2191,
          "minimum": 460.11,
          "maximum": 1604.2502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1122.9751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LIGHT 03.615.132S",
      "code_information": [
        {
          "code": "3549136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1748,
          "minimum": 367.08,
          "maximum": 1279.8856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 895.9199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 388.175",
      "code_information": [
        {
          "code": "3549150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1078,
          "minimum": 226.38,
          "maximum": 789.3116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 552.5181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 9-0 V449G",
      "code_information": [
        {
          "code": "3549155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 112.7588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHALANGEAL 20MM",
      "code_information": [
        {
          "code": "3549160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADER-TRIAL DRG 7032ANS",
      "code_information": [
        {
          "code": "3549166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1376.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULAIDE-CPAP SIZE 2, CA102-",
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        {
          "code": "3549182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.0816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL PRP ABS-10061T",
      "code_information": [
        {
          "code": "3549185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1117.8497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.021S",
      "code_information": [
        {
          "code": "3549190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2362,
          "minimum": 496.02,
          "maximum": 1729.4564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1210.6195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703713",
      "code_information": [
        {
          "code": "3549201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 867.2177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TAP 12.5MM 338.17",
      "code_information": [
        {
          "code": "3549204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1370.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- CANN 6.5MM 702603",
      "code_information": [
        {
          "code": "3549216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2032,
          "minimum": 426.72,
          "maximum": 1487.8304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1041.4813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CSG WORLEY STANDARD",
      "code_information": [
        {
          "code": "3549218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1900,
          "minimum": 399,
          "maximum": 1391.18,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 973.826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-LAT VEIN WORLEY",
      "code_information": [
        {
          "code": "3549219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2264,
          "minimum": 475.44,
          "maximum": 1657.7008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1160.3906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-UNCUFFED 7.0 70XLTUP",
      "code_information": [
        {
          "code": "3549227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 346.477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.1X87 A-3836",
      "code_information": [
        {
          "code": "3549229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-PCL 2.4MMX10",
      "code_information": [
        {
          "code": "3549231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 702.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CROSS PLATE 705172",
      "code_information": [
        {
          "code": "3549243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2762,
          "minimum": 580.02,
          "maximum": 2022.3364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1415.6355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL CPRP ABS-10063",
      "code_information": [
        {
          "code": "3549250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-THREAD LOCK 03.835.009S",
      "code_information": [
        {
          "code": "3549252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1698,
          "minimum": 356.58,
          "maximum": 1243.2756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 870.2929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPEEDGUIDE-T8 2.4/2.7X30MM",
      "code_information": [
        {
          "code": "3549269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2408,
          "minimum": 505.68,
          "maximum": 1763.1376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1234.1963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEEDGUIDE AO 2.0X30MM",
      "code_information": [
        {
          "code": "3549270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5577,
          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2858.4356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 2.1MM",
      "code_information": [
        {
          "code": "3549272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1742,
          "minimum": 365.82,
          "maximum": 1275.4924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 892.8447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS TRIPLE 91429",
      "code_information": [
        {
          "code": "3549278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 453,
          "minimum": 95.13,
          "maximum": 331.6866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 232.1806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.1X300MM RMT3130",
      "code_information": [
        {
          "code": "3549279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2423,
          "minimum": 508.83,
          "maximum": 1774.1206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1241.8844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-2.5 SOLID HT-2502",
      "code_information": [
        {
          "code": "3549283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 770.8602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Y-PORT-20 FR M00580641",
      "code_information": [
        {
          "code": "3549284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-DHS REAMER 338.13",
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        {
          "code": "3549287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7319,
          "minimum": 1536.99,
          "maximum": 5358.9718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3751.2803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOAM-BUMP 10X6X6\\\" DYNJBUMP03",
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        {
          "code": "3549293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.5189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-PALM ROLYAN SOFT GEL LT",
      "code_information": [
        {
          "code": "3549295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 246,
          "minimum": 51.66,
          "maximum": 180.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 126.0848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FORCEP SUCTION 9G12R",
      "code_information": [
        {
          "code": "3549304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HUMIDIFIER ATSVII BE-1010",
      "code_information": [
        {
          "code": "3549307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CATH LINE 020378801",
      "code_information": [
        {
          "code": "3549311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM 6149.1035",
      "code_information": [
        {
          "code": "3549338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 650.114",
      "code_information": [
        {
          "code": "3549348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ANGLE 14MM 684.434",
      "code_information": [
        {
          "code": "3549349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5M SHORT 6149.1037",
      "code_information": [
        {
          "code": "3549352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 16MM 650.116",
      "code_information": [
        {
          "code": "3549372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 668.8647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD BK-IS 109185",
      "code_information": [
        {
          "code": "3549411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP 2.4MM",
      "code_information": [
        {
          "code": "3549451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 168.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB LARGE AR-8970-09",
      "code_information": [
        {
          "code": "3549452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 722.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ADAPTER BIOPSY MAJ-1414",
      "code_information": [
        {
          "code": "3549507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-THUMB SPICA ANY    350S",
      "code_information": [
        {
          "code": "3549700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUICKCLOT 8X8 4010",
      "code_information": [
        {
          "code": "3549703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 533.5541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-COMFY FINGER",
      "code_information": [
        {
          "code": "3549716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.2791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 6 6SIC",
      "code_information": [
        {
          "code": "3549725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.0424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 8 8SIC",
      "code_information": [
        {
          "code": "3549726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.0424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUIKCLOT 5X5 4000",
      "code_information": [
        {
          "code": "3549730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 733,
          "minimum": 153.93,
          "maximum": 536.7026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 375.6918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOCN0346",
      "code_information": [
        {
          "code": "3549731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 392.0931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 200 AC-10030100",
      "code_information": [
        {
          "code": "3549732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3289,
          "minimum": 690.69,
          "maximum": 2408.2058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1685.7441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ESOPHAGEAL 100001",
      "code_information": [
        {
          "code": "3549734",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BV175-6 BLUE EPM8743",
      "code_information": [
        {
          "code": "3549735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 607,
          "minimum": 127.47,
          "maximum": 444.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 311.1118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 365 AC-10030110",
      "code_information": [
        {
          "code": "3549736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1324.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LONG TUNNELING SC-4254",
      "code_information": [
        {
          "code": "3549742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1032.2556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM 03.010.061",
      "code_information": [
        {
          "code": "3549747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1751,
          "minimum": 367.71,
          "maximum": 1282.0822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 897.4575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 16MM 03.037.002",
      "code_information": [
        {
          "code": "3549748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5189,
          "minimum": 1089.69,
          "maximum": 3799.3858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2659.5701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 6-9MM 03.037.022",
      "code_information": [
        {
          "code": "3549750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3479,
          "minimum": 730.59,
          "maximum": 2547.3238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1783.1267,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-BABYFLOW PLUS S DISP MP37",
      "code_information": [
        {
          "code": "3549751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.5331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-DISP",
      "code_information": [
        {
          "code": "3549752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.2321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEOMASK-CPAP",
      "code_information": [
        {
          "code": "3549753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BABUFLOE SZ 4 DISP MP0149",
      "code_information": [
        {
          "code": "3549754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 225,
          "minimum": 47.25,
          "maximum": 164.745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.3215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP",
      "code_information": [
        {
          "code": "3549755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PNEUMOTHORAX G05297",
      "code_information": [
        {
          "code": "3549757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1013,
          "minimum": 212.73,
          "maximum": 741.7186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 519.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOURNIQUET-TACTICAL 30-0023",
      "code_information": [
        {
          "code": "3549759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 360,
          "minimum": 75.6,
          "maximum": 263.592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.5144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R001",
      "code_information": [
        {
          "code": "3549765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1324.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-A003",
      "code_information": [
        {
          "code": "3549766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1633.9775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-SEATTLE PLUS MP02260",
      "code_information": [
        {
          "code": "3549776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 289.0726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE HINGED DONJOY",
      "code_information": [
        {
          "code": "3549781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 872,
          "minimum": 183.12,
          "maximum": 638.4784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 446.9349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-DISTAL 24MM 03.211.024",
      "code_information": [
        {
          "code": "3549786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1353.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PROX 24MM 03.211.124",
      "code_information": [
        {
          "code": "3549787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1353.1056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL SINGLE PK 1",
      "code_information": [
        {
          "code": "3549805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 508.4397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROCESSOR-SOUND LINE 90711",
      "code_information": [
        {
          "code": "3549810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-BAHA STORAGE Z342010",
      "code_information": [
        {
          "code": "3549811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-PERFORM REV PERI MWJ126",
      "code_information": [
        {
          "code": "3549818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 514.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5X220MM DWD017",
      "code_information": [
        {
          "code": "3549819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 950,
          "minimum": 199.5,
          "maximum": 695.59,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 486.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-0xx-000",
      "code_information": [
        {
          "code": "3549839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SHAFT 8X510 0227-8510S",
      "code_information": [
        {
          "code": "3549851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1867,
          "minimum": 392.07,
          "maximum": 1367.0174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 956.9122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LOCKING 705078",
      "code_information": [
        {
          "code": "3549854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1563,
          "minimum": 328.23,
          "maximum": 1144.4286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 801.1,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 700354",
      "code_information": [
        {
          "code": "3549867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1228,
          "minimum": 257.88,
          "maximum": 899.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 629.3991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW INFINITY 3600315",
      "code_information": [
        {
          "code": "3549870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.4 G3606010",
      "code_information": [
        {
          "code": "3549873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-STRAIGH TIP 2762-01-0004",
      "code_information": [
        {
          "code": "3549916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1617.0637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR NIM 945NSD2750",
      "code_information": [
        {
          "code": "3549918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAGITTAL 2296-003-155",
      "code_information": [
        {
          "code": "3549927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.8655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 2.4 1608-006-147",
      "code_information": [
        {
          "code": "3549928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 751,
          "minimum": 157.71,
          "maximum": 549.8822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 384.9175,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 1MM 1608-006-151",
      "code_information": [
        {
          "code": "3549929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 722,
          "minimum": 151.62,
          "maximum": 528.6484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 370.0539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-413S1",
      "code_information": [
        {
          "code": "3549931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.8655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 7X15MM 2296-003-103",
      "code_information": [
        {
          "code": "3549932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 267.0333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-111S5",
      "code_information": [
        {
          "code": "3549933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.8655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHORT 2.5MM 2296-003-413",
      "code_information": [
        {
          "code": "3549934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 256.7825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48X70MM 2108-197-00S4",
      "code_information": [
        {
          "code": "3549935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X75MM 4125-089-075",
      "code_information": [
        {
          "code": "3549936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 737,
          "minimum": 154.77,
          "maximum": 539.6314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 377.742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90 4125-097-090",
      "code_information": [
        {
          "code": "3549937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 307.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 13X90MM 4113-119-090",
      "code_information": [
        {
          "code": "3549938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 307.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-119-090",
      "code_information": [
        {
          "code": "3549939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 393.1182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-127-090",
      "code_information": [
        {
          "code": "3549940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 393.1182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-70X12.5MM 0277-096-277",
      "code_information": [
        {
          "code": "3549941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 572,
          "minimum": 120.12,
          "maximum": 418.8184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 293.1729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RECIPR. 0277-096-325",
      "code_information": [
        {
          "code": "3549942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 583,
          "minimum": 122.43,
          "maximum": 426.8726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 298.8108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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        },
        {
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        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-18.5X90.5 2108-382-003",
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          "type": "LOCAL"
        },
        {
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        }
      ],
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        {
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          "minimum": 129.78,
          "maximum": 452.4996,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE,SAW VASC 5400-134-415",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
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    },
    {
      "description": "BLADE, SAW 25X90MM 6725-127-09",
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        },
        {
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        }
      ],
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        {
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            }
          ]
        }
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    },
    {
      "description": "COIL-EMBOLIZATION 8MM M0013635",
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        {
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          ]
        }
      ],
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    },
    {
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          ]
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    {
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          ]
        }
      ],
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    {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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        {
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          ]
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      "service_type": "CDM"
    },
    {
      "description": "STEM-TIB 42-5320-064-02",
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            }
          ]
        }
      ],
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    },
    {
      "description": "GUIDE-REVERSED GLEN MWJ004",
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            }
          ]
        }
      ],
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    },
    {
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          ]
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      ],
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    {
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            {
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            }
          ]
        }
      ],
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    },
    {
      "description": "VALVE-DSIP RFID EXPIRATORY MP0",
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        {
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      ],
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        {
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            }
          ]
        }
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    },
    {
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        {
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      ],
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          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 65.31,
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            }
          ]
        }
      ],
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    },
    {
      "description": "BLADE-LARYN C-MAC #3 MILLER",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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      ],
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        {
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          ]
        }
      ],
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    {
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    {
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          ]
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      ],
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    {
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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        {
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          ]
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      ],
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    },
    {
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            }
          ]
        }
      ],
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    },
    {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        }
      ],
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            }
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        }
      ],
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    },
    {
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        },
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CAN 190MM 03.010.036",
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          "code": "3550091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-W/F L&L PED ALL 5002s",
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        {
          "code": "3550092",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 6MMX10CM M00",
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        {
          "code": "3550094",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 531.09,
          "maximum": 1851.7338,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-ANNULOTOMY 675.405S",
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        {
          "code": "3550111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-SHIM SS 6133.0326S",
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        {
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-BRILL 3.5 682.108S",
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        {
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        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
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          "minimum": 95.34,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.914S",
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        {
          "code": "3550136",
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        {
          "code": "0270",
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      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CT 3.5M 6149.9135",
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        {
          "code": "3550137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIABETIC FOOT CARE 0811748",
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        {
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        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 71MM 705506",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 256.83,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X25MM 7005-3325",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT RSZ4001S",
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        {
          "code": "3550168",
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        },
        {
          "code": "0270",
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW 1020-00-000",
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        {
          "code": "3550179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-C001",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 296.1,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22GX9CM",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.8X122 A-3738",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIMED RX COUDE 1314ANS",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CERV MOBI-C 13X17 MB3375",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 4599.42,
          "maximum": 16036.6444,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPAR 14MM 0024-LDR",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYGEN VOCSN PRT-00930",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 82.53,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE 2.5MM 694",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-T 601.800",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 732.27,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPANNER-WRENCH 687.509",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "TUBE-INSERTER 694.004",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-INSERTER 694.005",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-CALIBER GRAPHIC 994.001",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "KIT-ARGYLE SHUNT 8888577775",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND A31216",
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        {
          "code": "3550250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-MEPITEL 6.8X10",
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        {
          "code": "3550253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 12FR 1.0CM",
      "code_information": [
        {
          "code": "3550256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 492.5509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-I/A CAPSULGUARD",
      "code_information": [
        {
          "code": "3550264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE RT SM 70831",
      "code_information": [
        {
          "code": "3550272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 338,
          "minimum": 70.98,
          "maximum": 247.4836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 173.2385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE LT SM 70831",
      "code_information": [
        {
          "code": "3550273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.4392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-OSTEOFUZE OF-BMA-11",
      "code_information": [
        {
          "code": "3550274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8800,
          "minimum": 1848,
          "maximum": 6443.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4510.352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET REUSE",
      "code_information": [
        {
          "code": "3550275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 870,
          "minimum": 182.7,
          "maximum": 637.014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 445.9098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-HEMOSTATIC POWDER 1978",
      "code_information": [
        {
          "code": "3550278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 379.2796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R002",
      "code_information": [
        {
          "code": "3550306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1324.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TROCAR THORACIC 24FR SWD",
      "code_information": [
        {
          "code": "3550314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-INSPIRA BREAST SRM",
      "code_information": [
        {
          "code": "3550331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4485,
          "minimum": 941.85,
          "maximum": 3283.917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2298.7419,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP 180-210CC",
      "code_information": [
        {
          "code": "3550332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DEFENDO Y-OPSY 100303",
      "code_information": [
        {
          "code": "3550394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.6161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PUSHLOCK 2.9MM",
      "code_information": [
        {
          "code": "3550395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 589.9335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM",
      "code_information": [
        {
          "code": "3550396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.0293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH 8MM 100/897/080",
      "code_information": [
        {
          "code": "3550399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 878,
          "minimum": 184.38,
          "maximum": 642.8716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 450.0101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER 8MM 100/890/080",
      "code_information": [
        {
          "code": "3550400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 18FR 897518",
      "code_information": [
        {
          "code": "3550406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 195,
          "minimum": 40.95,
          "maximum": 142.779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.9453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-TRIPLE NEEDLE INS-5300",
      "code_information": [
        {
          "code": "3550411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4172,
          "minimum": 876.12,
          "maximum": 3054.7384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2138.3169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPIN W/ADAPTER INS-5910",
      "code_information": [
        {
          "code": "3550414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4906,
          "minimum": 1030.26,
          "maximum": 3592.1732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2514.5212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J556G",
      "code_information": [
        {
          "code": "3550419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.7948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0 770G",
      "code_information": [
        {
          "code": "3550420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 102.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8695G",
      "code_information": [
        {
          "code": "3550421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STATLOCK-URO FOLEY FOL0105",
      "code_information": [
        {
          "code": "3550423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-REDDIE KNEE XL 08154723",
      "code_information": [
        {
          "code": "3550426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 223.98,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-BACK ROLYANFIT MESH",
      "code_information": [
        {
          "code": "3550427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 136.8482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-2.3MM PED SCREW 4008-00",
      "code_information": [
        {
          "code": "3550429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER",
      "code_information": [
        {
          "code": "3550432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 330.5883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING RS5200",
      "code_information": [
        {
          "code": "3550447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5472,
          "minimum": 1149.12,
          "maximum": 4006.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2804.6189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-FIXATION LG FP9000L",
      "code_information": [
        {
          "code": "3550448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 299.8359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL",
      "code_information": [
        {
          "code": "3550461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 509.4648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-PRIME 286750200S",
      "code_information": [
        {
          "code": "3550473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1376.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-MMG 2862-02-108",
      "code_information": [
        {
          "code": "3550480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1175,
          "minimum": 246.75,
          "maximum": 860.335,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 602.2345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STEM 2862-02-204",
      "code_information": [
        {
          "code": "3550481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1203.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 03.010.060",
      "code_information": [
        {
          "code": "3550483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1814,
          "minimum": 380.94,
          "maximum": 1328.2108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 929.7476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-120",
      "code_information": [
        {
          "code": "3550487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 516.1278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-120LP",
      "code_information": [
        {
          "code": "3550488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 491.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MACY BEDSIDE DELIVERY M",
      "code_information": [
        {
          "code": "3550498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 932,
          "minimum": 195.72,
          "maximum": 682.4104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 477.6873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PRESSURE OPAQUE 50P148",
      "code_information": [
        {
          "code": "3550499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH,MALE EXTERNAL",
      "code_information": [
        {
          "code": "3550511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH PEDIATRIC",
      "code_information": [
        {
          "code": "3550515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO CF DEL FGS-0635",
      "code_information": [
        {
          "code": "3550530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2212,
          "minimum": 464.52,
          "maximum": 1619.6264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1133.7385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM ST 6149.1036S",
      "code_information": [
        {
          "code": "3550541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 508.4397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF XL MDS601BD",
      "code_information": [
        {
          "code": "3550555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.0456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT MED MDS620",
      "code_information": [
        {
          "code": "3550556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 257,
          "minimum": 53.97,
          "maximum": 188.1754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 131.7228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT LRG MDS620L",
      "code_information": [
        {
          "code": "3550557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 277,
          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.9736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH MED MDS630MD",
      "code_information": [
        {
          "code": "3550558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 351,
          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 179.9015,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH LRG MDS630LD",
      "code_information": [
        {
          "code": "3550559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH X-LG MDS630BD",
      "code_information": [
        {
          "code": "3550560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 383,
          "minimum": 80.43,
          "maximum": 280.4326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 196.3028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT 10° TIP MLD-0068",
      "code_information": [
        {
          "code": "3550592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1617.0637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.5X350MM PK6 MLD-0301",
      "code_information": [
        {
          "code": "3550593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.4351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-8/13/18MM MLD-0441S",
      "code_information": [
        {
          "code": "3550594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2529.8974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIM-SPIKE BLUNT MLD-0513",
      "code_information": [
        {
          "code": "3550595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1873,
          "minimum": 393.33,
          "maximum": 1371.4106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 959.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- DILATOR MLD-0345",
      "code_information": [
        {
          "code": "3550596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.4351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153207",
      "code_information": [
        {
          "code": "3550599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-THORACIC TGMR312610",
      "code_information": [
        {
          "code": "3550613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84847,
          "minimum": 17817.87,
          "maximum": 62124.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43487.4814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X12MM 03.501.762",
      "code_information": [
        {
          "code": "3550619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2487,
          "minimum": 522.27,
          "maximum": 1820.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1274.687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX16CM",
      "code_information": [
        {
          "code": "3550630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 293.6854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX16CM",
      "code_information": [
        {
          "code": "3550631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICAL SCREW 3603-00-TE",
      "code_information": [
        {
          "code": "3550634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PEDIATRIC YG-232T",
      "code_information": [
        {
          "code": "3550638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.7871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT LARGE YG-282T",
      "code_information": [
        {
          "code": "3550639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.8951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC 153509",
      "code_information": [
        {
          "code": "3550645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3ML 165810",
      "code_information": [
        {
          "code": "3550646",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-MARKING ROBOTIP INFARED",
      "code_information": [
        {
          "code": "3550649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE F/MRI SQK65VS",
      "code_information": [
        {
          "code": "3550657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 116.3466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE,FLEX FLEX-200-QFT",
      "code_information": [
        {
          "code": "3550658",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.3183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 0200-20",
      "code_information": [
        {
          "code": "3550659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 709.3554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE 24F 5CC 0",
      "code_information": [
        {
          "code": "3550665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 170,
          "minimum": 35.7,
          "maximum": 124.474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ASSEMBLY DISP 83030-1",
      "code_information": [
        {
          "code": "3550668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1576,
          "minimum": 330.96,
          "maximum": 1153.9472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 807.763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY 18G ANG 221251",
      "code_information": [
        {
          "code": "3550683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.3685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-BONE 3.8X13CM AR-8380BC",
      "code_information": [
        {
          "code": "3550684",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 403.8815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VS-1 5FR 80CM BEACON TIP",
      "code_information": [
        {
          "code": "3550691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.8012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL DETACHMENT RH1",
      "code_information": [
        {
          "code": "3550699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 819.0389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE D9212",
      "code_information": [
        {
          "code": "3550703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1077,
          "minimum": 226.17,
          "maximum": 788.5794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 552.0056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SMARTRELEASE ONYX 83030-",
      "code_information": [
        {
          "code": "3550710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1969,
          "minimum": 413.49,
          "maximum": 1441.7018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1009.1913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM 2.3MM 2862-02-201",
      "code_information": [
        {
          "code": "3550713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3171,
          "minimum": 665.91,
          "maximum": 2321.8062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1625.2643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE ULTRASOUND 8’ CVC6",
      "code_information": [
        {
          "code": "3550720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.6193,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BONE HARVEST 03.404.000S",
      "code_information": [
        {
          "code": "3550737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12726,
          "minimum": 2672.46,
          "maximum": 9317.9772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6522.584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MENISCAL ROOT 71935068",
      "code_information": [
        {
          "code": "3550740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5252,
          "minimum": 1102.92,
          "maximum": 3845.5144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2691.8601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-REAMER",
      "code_information": [
        {
          "code": "3550752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3893,
          "minimum": 817.53,
          "maximum": 2850.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1995.3182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXY ADULT ETCO2 OM-2125-8",
      "code_information": [
        {
          "code": "3550753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXYTYKE INFNT W/7’ TUBING",
      "code_information": [
        {
          "code": "3550754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONET 188MM 1563-00",
      "code_information": [
        {
          "code": "3550760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1032.2556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT INTERSTIM 3560022",
      "code_information": [
        {
          "code": "3550762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1631,
          "minimum": 342.51,
          "maximum": 1194.2182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 835.9527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 3MM BIT DK-300",
      "code_information": [
        {
          "code": "3550765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2326,
          "minimum": 488.46,
          "maximum": 1703.0972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1192.168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DECOMPRESSION ZZ-0056",
      "code_information": [
        {
          "code": "3550777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,LASER TRACH",
      "code_information": [
        {
          "code": "3550778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 675.725S",
      "code_information": [
        {
          "code": "3550783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4163.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP THR 1.35M",
      "code_information": [
        {
          "code": "3550793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 152.7369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0 8762H",
      "code_information": [
        {
          "code": "3550794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (15) 8800966",
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        {
          "code": "3550803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (5) 8801002",
      "code_information": [
        {
          "code": "3550804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 172.726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 4.6X220 P99-110-4622",
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        {
          "code": "3550805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1591,
          "minimum": 334.11,
          "maximum": 1164.9302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 815.4511,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110MM 213524",
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        {
          "code": "3550809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 484.3503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM ADJ 2862-02-200",
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        {
          "code": "3550815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3171,
          "minimum": 665.91,
          "maximum": 2321.8062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1625.2643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.1X50 M-R 01-7141",
      "code_information": [
        {
          "code": "3550816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1472,
          "minimum": 309.12,
          "maximum": 1077.7984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 754.4589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL EMBOLIZATION PODH1",
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        {
          "code": "3550822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 819.0389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 AO A-8004.03",
      "code_information": [
        {
          "code": "3550830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1879,
          "minimum": 394.59,
          "maximum": 1375.8038,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 963.0627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 16FR PEDS 8016",
      "code_information": [
        {
          "code": "3550842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 57.4045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CLEARCUT 5X13 AR-8500COS",
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        {
          "code": "3550848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 403.8815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.45MM SM 45303145",
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        {
          "code": "3550850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAGE-12MM/8° 50/18 LUI81249",
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        {
          "code": "3550854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 19856,
          "minimum": 4169.76,
          "maximum": 14538.5632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 10176.9942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-CUSTOM MED PK623984",
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        {
          "code": "3550856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52648,
          "minimum": 11056.08,
          "maximum": 38548.8656,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 26984.2059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BAL RX DC-RYxxxxxx",
      "code_information": [
        {
          "code": "3550857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-R2P MISAGO SXRxxxxxx",
      "code_information": [
        {
          "code": "3550858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4415,
          "minimum": 927.15,
          "maximum": 3232.663,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2262.8641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-METACROSS BD-xxxxxxxx",
      "code_information": [
        {
          "code": "3550859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1850,
          "minimum": 388.5,
          "maximum": 1354.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 948.199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT F/2.16MM 3560030",
      "code_information": [
        {
          "code": "3550864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-INTERPULSE",
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        {
          "code": "3550869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-SKULL MOUNT 9735300",
      "code_information": [
        {
          "code": "3550873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1643,
          "minimum": 345.03,
          "maximum": 1203.0046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 842.1032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16FR A3",
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        {
          "code": "3550876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 223.98,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0X150MM 705234",
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        {
          "code": "3550888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 903,
          "minimum": 189.63,
          "maximum": 661.1766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 462.8236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PERFORATED FUNCTIONAL 0",
      "code_information": [
        {
          "code": "3550898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 147.6115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-HI-SPEED 4X11 1884068HS",
      "code_information": [
        {
          "code": "3550911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2381,
          "minimum": 500.01,
          "maximum": 1743.3682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1220.3577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PROLAPSE HEM3335",
      "code_information": [
        {
          "code": "3550912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2317,
          "minimum": 486.57,
          "maximum": 1696.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1187.5552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM XT SIGTRSB60AXT",
      "code_information": [
        {
          "code": "3550915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3076,
          "minimum": 645.96,
          "maximum": 2252.2472,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM MT SIGTRSB60AMT",
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        {
          "code": "3550916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1307.4895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
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        {
          "code": "3551250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 84.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT  STR 35R",
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        {
          "code": "3552730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.0424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
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        {
          "code": "3552731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.3151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
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        {
          "code": "3552732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXW35",
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        {
          "code": "3552737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKING-COMPRESSION CUSTOM",
      "code_information": [
        {
          "code": "3553701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 307.0115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-BONE",
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        {
          "code": "3554025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9164,
          "minimum": 1924.44,
          "maximum": 6709.8808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4696.9166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CLAVICAL ADULT ALL 3001s",
      "code_information": [
        {
          "code": "3554085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "3554974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3554981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 213.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-1/2\\\"X2\\\" SMALL    1955",
      "code_information": [
        {
          "code": "3555059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.3639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2\\\"X14\\\" LARGE     1951",
      "code_information": [
        {
          "code": "3555109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 405.9317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2 X 3 MEDIUM     1953",
      "code_information": [
        {
          "code": "3555158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 489,
          "minimum": 102.69,
          "maximum": 358.0458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 250.6321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP MED  202549",
      "code_information": [
        {
          "code": "3555307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP LG   202636",
      "code_information": [
        {
          "code": "3555315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORIE-XLGE 202612&201352",
      "code_information": [
        {
          "code": "3555323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 493,
          "minimum": 103.53,
          "maximum": 360.9746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 252.6822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       G121H",
      "code_information": [
        {
          "code": "3555374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0 FS-2   636H",
      "code_information": [
        {
          "code": "3555390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 5.1254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-DEXON           7618-41",
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        {
          "code": "3556875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 9.03,
          "maximum": 31.4846,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 22.0392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0   1663H",
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        {
          "code": "3557098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 8.61,
          "maximum": 30.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 21.0141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3557628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5.1254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 6-0 P1       697G",
      "code_information": [
        {
          "code": "3557898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.3151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        698H",
      "code_information": [
        {
          "code": "3557956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        990H",
      "code_information": [
        {
          "code": "3558678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685G",
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        {
          "code": "3558679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 16,
          "minimum": 3.36,
          "maximum": 11.7152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 8.2006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1653-G",
      "code_information": [
        {
          "code": "3558947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1663-H",
      "code_information": [
        {
          "code": "3558970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 49,
          "minimum": 10.29,
          "maximum": 35.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 25.1145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0       1667G",
      "code_information": [
        {
          "code": "3558978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 3-0       1669H",
      "code_information": [
        {
          "code": "3558982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4.5MM 080-453",
      "code_information": [
        {
          "code": "3559003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE P99-930-2108",
      "code_information": [
        {
          "code": "3559011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3368,
          "minimum": 707.28,
          "maximum": 2466.0496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1726.2347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND 2.5MM 1882569HS",
      "code_information": [
        {
          "code": "3559015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1938,
          "minimum": 406.98,
          "maximum": 1419.0036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 993.3025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       G695G",
      "code_information": [
        {
          "code": "3559030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1696-G",
      "code_information": [
        {
          "code": "3559036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.0534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON           1698G",
      "code_information": [
        {
          "code": "3559069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM MT SIGTRSB45AMT",
      "code_information": [
        {
          "code": "3559071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2310,
          "minimum": 485.1,
          "maximum": 1691.382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.9674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FEMALE EXT PWF-030K",
      "code_information": [
        {
          "code": "3559082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.8559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-LONG 4.2MM 703545",
      "code_information": [
        {
          "code": "3559085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3448,
          "minimum": 724.08,
          "maximum": 2524.6256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1767.2379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-5X100MM FIX UNVCA5STF",
      "code_information": [
        {
          "code": "3559095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 156,
          "minimum": 32.76,
          "maximum": 114.2232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 15MM ONB15STF",
      "code_information": [
        {
          "code": "3559096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 228.0803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 5MM ONB5STF",
      "code_information": [
        {
          "code": "3559097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 286,
          "minimum": 60.06,
          "maximum": 209.4092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 146.5864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3559115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 12FR 0200-12L",
      "code_information": [
        {
          "code": "3559117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 709.3554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM CDH29P",
      "code_information": [
        {
          "code": "3559120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2660,
          "minimum": 558.6,
          "maximum": 1947.652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1363.3564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3559142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2143,
          "minimum": 450.03,
          "maximum": 1569.1046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1098.3732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15MM XTHICK SIG60AXT",
      "code_information": [
        {
          "code": "3559150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1896,
          "minimum": 398.16,
          "maximum": 1388.2512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 971.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1065832",
      "code_information": [
        {
          "code": "3559158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIAMONDTOUCH IN9152",
      "code_information": [
        {
          "code": "3559159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 632,
          "minimum": 132.72,
          "maximum": 462.7504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 323.9253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN GUARD",
      "code_information": [
        {
          "code": "3559160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1386.4207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLLEVE-SPIN GUARD",
      "code_information": [
        {
          "code": "3559161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1702,
          "minimum": 357.42,
          "maximum": 1246.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 872.3431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYDROGEL EEG",
      "code_information": [
        {
          "code": "3559175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J493H",
      "code_information": [
        {
          "code": "3559178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0 1635G",
      "code_information": [
        {
          "code": "3559179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.2038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J670G",
      "code_information": [
        {
          "code": "3559180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.7697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP497G",
      "code_information": [
        {
          "code": "3559181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 185,
          "minimum": 38.85,
          "maximum": 135.457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.8199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPREADER-SILIPOS GEL TOE MED",
      "code_information": [
        {
          "code": "3559185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-12MM 10*/MD 08.815.242S",
      "code_information": [
        {
          "code": "3559197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 23165,
          "minimum": 4864.65,
          "maximum": 16961.413,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 11872.9891,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW-ACC BONCH AF541",
      "code_information": [
        {
          "code": "3559228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW,STD BLUE AF541 73-112096",
      "code_information": [
        {
          "code": "3559229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM/MED/LG",
      "code_information": [
        {
          "code": "3559240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 39.69,
          "maximum": 138.3858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LAMINARIA-#4 MED 60MM 021004",
      "code_information": [
        {
          "code": "3559244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.2MM XS 45303125",
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        {
          "code": "3559246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD 4033A",
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        {
          "code": "3559253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X40MM 7005-3340",
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        {
          "code": "3559254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X60MM 7005-3360",
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        {
          "code": "3559255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 10G 0306-530-000",
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        {
          "code": "3559260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 134.82,
          "maximum": 470.0724,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 329.0507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ TRANS 0909-400-500",
      "code_information": [
        {
          "code": "3559261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 1025-011-500",
      "code_information": [
        {
          "code": "3559262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 497.07,
          "maximum": 1733.1174,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1213.1822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CEMENT 0306-410-000",
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        {
          "code": "3559263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 604,
          "minimum": 126.84,
          "maximum": 442.2488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 309.5742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INDIGO SEP12",
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        {
          "code": "3559264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8101,
          "minimum": 1701.21,
          "maximum": 5931.5522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4152.0865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURRETTE-10G 0306-621-000",
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        {
          "code": "3559265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3257,
          "minimum": 683.97,
          "maximum": 2384.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1669.3428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FLEX CUFFED",
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        {
          "code": "3559271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 157.5,
          "maximum": 549.15,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 384.405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-FLEXIBLE 2.9MM 682.622",
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        {
          "code": "3559276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1032.2556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2516H",
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        {
          "code": "3559281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 53.3042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COILED 60\\\" CT 100113",
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        {
          "code": "3559287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-GPS 3.5MM 6143.2572",
      "code_information": [
        {
          "code": "3559291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4.2X360/SM 1320-3642S",
      "code_information": [
        {
          "code": "3559293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 491.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383593",
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        {
          "code": "3559297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 58.4296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON BLK 4-0   1854G",
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        {
          "code": "3559366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 PC-1  1855G",
      "code_information": [
        {
          "code": "3559390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER 4MM SB4000SA",
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        {
          "code": "3559391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 244.02,
          "maximum": 850.8164,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 595.5715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING 19F L",
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        {
          "code": "3559394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 71.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCESS 8MM",
      "code_information": [
        {
          "code": "3559395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 939,
          "minimum": 197.19,
          "maximum": 687.5358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 481.2751,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3559401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1438,
          "minimum": 301.98,
          "maximum": 1052.9036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 737.0325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FIBERLASE CO2",
      "code_information": [
        {
          "code": "3559407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2602.1656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0/PC-3  1865G",
      "code_information": [
        {
          "code": "3559425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MIC J FEDDING 8200",
      "code_information": [
        {
          "code": "3559430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 709.3554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT SINGLE 5' RT219",
      "code_information": [
        {
          "code": "3559433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 377,
          "minimum": 79.17,
          "maximum": 276.0394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 193.2276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT DUAL HTDRT380",
      "code_information": [
        {
          "code": "3559434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 386,
          "minimum": 81.06,
          "maximum": 282.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.8404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 EPM8706",
      "code_information": [
        {
          "code": "3559435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 814,
          "minimum": 170.94,
          "maximum": 596.0108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 417.2076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT OPEN EB240",
      "code_information": [
        {
          "code": "3559437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1169.6163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 2X315MM 703561",
      "code_information": [
        {
          "code": "3559445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.2449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VIZISNOT2 19G",
      "code_information": [
        {
          "code": "3559447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2067,
          "minimum": 434.07,
          "maximum": 1513.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1059.4202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIP 8.5X110 72200436",
      "code_information": [
        {
          "code": "3559448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X56MM 03.130.202",
      "code_information": [
        {
          "code": "3559456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.100",
      "code_information": [
        {
          "code": "3559462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 530.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 K-WIRE",
      "code_information": [
        {
          "code": "3559463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 509.4648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 22X10MM 03.501.760",
      "code_information": [
        {
          "code": "3559485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2487,
          "minimum": 522.27,
          "maximum": 1820.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1274.687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2590S",
      "code_information": [
        {
          "code": "3559495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 145.5614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2591S",
      "code_information": [
        {
          "code": "3559496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 145.5614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM GPS 6143.2580S",
      "code_information": [
        {
          "code": "3559499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 946.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM GPS 6143.2582S",
      "code_information": [
        {
          "code": "3559500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 946.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM GPS 6143.2584S",
      "code_information": [
        {
          "code": "3559501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 946.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 8FR G00980",
      "code_information": [
        {
          "code": "3559527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-6MM BALT 110135",
      "code_information": [
        {
          "code": "3559542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 710,
          "minimum": 149.1,
          "maximum": 519.862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 363.9034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 116239",
      "code_information": [
        {
          "code": "3559543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1039,
          "minimum": 218.19,
          "maximum": 760.7558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 532.5291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-OVASSAPIAN 85MM BD6075",
      "code_information": [
        {
          "code": "3559545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/55 STANDARD 7607",
      "code_information": [
        {
          "code": "3559546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2974,
          "minimum": 624.54,
          "maximum": 2177.5628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1524.294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8340050",
      "code_information": [
        {
          "code": "3559560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9498,
          "minimum": 1994.58,
          "maximum": 6954.4356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4868.1049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y3/8X3/16X3/16 10518",
      "code_information": [
        {
          "code": "3559582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CABLE 323.1090",
      "code_information": [
        {
          "code": "3559590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1886,
          "minimum": 396.06,
          "maximum": 1380.9292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 966.6504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BRAD POINT 4MM 323.010",
      "code_information": [
        {
          "code": "3559591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2034,
          "minimum": 427.14,
          "maximum": 1489.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1042.5064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRIPLE LUMEN 5.5FR",
      "code_information": [
        {
          "code": "3559593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1240,
          "minimum": 260.4,
          "maximum": 907.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 635.5496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL LUMEN 4FR",
      "code_information": [
        {
          "code": "3559594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1190,
          "minimum": 249.9,
          "maximum": 871.318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 609.9226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 4.5X15 9009-2001",
      "code_information": [
        {
          "code": "3559598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3360,
          "minimum": 705.6,
          "maximum": 2460.192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1722.1344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM XT SIGTRSB45AXT",
      "code_information": [
        {
          "code": "3559607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2514,
          "minimum": 527.94,
          "maximum": 1840.7508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1288.5256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/F P01-900-1902",
      "code_information": [
        {
          "code": "3559612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1386.4207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/M P01-900-1903",
      "code_information": [
        {
          "code": "3559613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1386.4207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEE-UTILIZATION PER CASE",
      "code_information": [
        {
          "code": "3559626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4344,
          "minimum": 912.24,
          "maximum": 3180.6768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2226.4738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV",
      "code_information": [
        {
          "code": "3559628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.0MM 705360",
      "code_information": [
        {
          "code": "3559634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1250,
          "minimum": 262.5,
          "maximum": 915.25,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 640.675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SENSOR SPO2 1822A-25",
      "code_information": [
        {
          "code": "3559649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 66.1177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASO 12FR",
      "code_information": [
        {
          "code": "3559651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.5691,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A435",
      "code_information": [
        {
          "code": "3559659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 201.4282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWRIST 2.5MM 60-25326",
      "code_information": [
        {
          "code": "3559663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 569.9445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #4 051114-10",
      "code_information": [
        {
          "code": "3559671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 124.0347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC",
      "code_information": [
        {
          "code": "3559672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 341,
          "minimum": 71.61,
          "maximum": 249.6802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 174.7761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 3.5X65",
      "code_information": [
        {
          "code": "3559673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1828,
          "minimum": 383.88,
          "maximum": 1338.4616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 936.9231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURETTE-0* TIP TDC005",
      "code_information": [
        {
          "code": "3559688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1117.8497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-0* TIP NAVIGATION",
      "code_information": [
        {
          "code": "3559690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON SILK    C-021-",
      "code_information": [
        {
          "code": "3560079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PS-2/4-0   J496G",
      "code_information": [
        {
          "code": "3560474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J492G",
      "code_information": [
        {
          "code": "3560778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J493G",
      "code_information": [
        {
          "code": "3560802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J494G",
      "code_information": [
        {
          "code": "3560836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 4-0  J-496-H",
      "code_information": [
        {
          "code": "3560879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.2399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-497-G",
      "code_information": [
        {
          "code": "3560893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-774-D",
      "code_information": [
        {
          "code": "3561255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.1569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J762D",
      "code_information": [
        {
          "code": "3561415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.4328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0        699H",
      "code_information": [
        {
          "code": "3561696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y496G",
      "code_information": [
        {
          "code": "3562112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.1537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y494G",
      "code_information": [
        {
          "code": "3562131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS-2    1666",
      "code_information": [
        {
          "code": "3562141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 40,
          "minimum": 8.4,
          "maximum": 29.288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 20.5016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8619G",
      "code_information": [
        {
          "code": "3562217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8699G",
      "code_information": [
        {
          "code": "3562235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.0784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIVERSAL*****",
      "code_information": [
        {
          "code": "3566070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-EAR DAVOL 3 OZ 529****",
      "code_information": [
        {
          "code": "3566353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 26.6521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CT FAST LOAD DUAL",
      "code_information": [
        {
          "code": "3566355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.5331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-PACK DUAL EMPOWERCTA",
      "code_information": [
        {
          "code": "3566380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CRANIAL ACCESS  INSHITH",
      "code_information": [
        {
          "code": "3566755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2554,
          "minimum": 536.34,
          "maximum": 1870.0388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1309.0272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MULTI PODUS 9274-56XX",
      "code_information": [
        {
          "code": "3566785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 982,
          "minimum": 206.22,
          "maximum": 719.0204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 503.3143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NURSING SUPPLEMENTAL",
      "code_information": [
        {
          "code": "3566790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FECAL MANAGEMENT",
      "code_information": [
        {
          "code": "3566823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1240,
          "minimum": 260.4,
          "maximum": 907.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 635.5496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-REPLACEMENT FECAL MGMT",
      "code_information": [
        {
          "code": "3566824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3567605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 921,
          "minimum": 193.41,
          "maximum": 674.3562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 472.0493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "THERMOSET-INJECTATE    4142403",
      "code_information": [
        {
          "code": "3568123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 8.0MM",
      "code_information": [
        {
          "code": "3568561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 228.0803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 6.0MM",
      "code_information": [
        {
          "code": "3568562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 450,
          "minimum": 94.5,
          "maximum": 329.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 230.643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3568563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 228.0803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 508,
          "minimum": 106.68,
          "maximum": 371.9576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 260.3703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU UNCUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.3922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4259105",
      "code_information": [
        {
          "code": "3568757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 380,
          "minimum": 79.8,
          "maximum": 278.236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 194.7652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-NEONATAL   42634-05",
      "code_information": [
        {
          "code": "3568760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXISENSOR-PEDIATRIC D20",
      "code_information": [
        {
          "code": "3568762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 112.2463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565200",
      "code_information": [
        {
          "code": "3569240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 580.7078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565150",
      "code_information": [
        {
          "code": "3569242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 580.7078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16 FR",
      "code_information": [
        {
          "code": "3569250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 366,
          "minimum": 76.86,
          "maximum": 267.9852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 187.5896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18 FR",
      "code_information": [
        {
          "code": "3569252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 366,
          "minimum": 76.86,
          "maximum": 267.9852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 187.5896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH URETHRAL BARD 772415",
      "code_information": [
        {
          "code": "3569258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20,
          "minimum": 4.2,
          "maximum": 14.644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-ESOPH TRACH     5-18541",
      "code_information": [
        {
          "code": "3569601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1095,
          "minimum": 229.95,
          "maximum": 801.759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 561.2313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY CATH/DRN BAG 6176LL",
      "code_information": [
        {
          "code": "3569779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR   6146LL",
      "code_information": [
        {
          "code": "3569805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/ BAG 18FR  6148LL",
      "code_information": [
        {
          "code": "3569853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.8418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG LTX 16F 6165L",
      "code_information": [
        {
          "code": "3569870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.2038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-LOOP CCL DYNJ50892",
      "code_information": [
        {
          "code": "3570230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 155.8122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMBAR PUNCTURE ADT 4301C",
      "code_information": [
        {
          "code": "3570322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMB PUNC PED   4304C****",
      "code_information": [
        {
          "code": "3570330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PARA/PUD PHARMASEAL 4540A",
      "code_information": [
        {
          "code": "3570603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 6.0F",
      "code_information": [
        {
          "code": "3570605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 498.1889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 8.3F",
      "code_information": [
        {
          "code": "3570610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1211,
          "minimum": 254.31,
          "maximum": 886.6942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 620.6859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SINGLE TAP BLOCK SPEC015",
      "code_information": [
        {
          "code": "3570640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 687,
          "minimum": 144.27,
          "maximum": 503.0214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 352.115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-NICU UMBILICAL CATH",
      "code_information": [
        {
          "code": "3570745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 543,
          "minimum": 114.03,
          "maximum": 397.5846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 278.3092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-DRESSING CHANGE 4D",
      "code_information": [
        {
          "code": "3571200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 94.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-THORACENTESIS CURITY 5014*",
      "code_information": [
        {
          "code": "3571304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 144.5363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 16FR 0100-16LV",
      "code_information": [
        {
          "code": "3571985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 193.7401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING W/ST 10F 43\\\"",
      "code_information": [
        {
          "code": "3571990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.9813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 8.0     86552",
      "code_information": [
        {
          "code": "3572176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 6LPC",
      "code_information": [
        {
          "code": "3572189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 743,
          "minimum": 156.03,
          "maximum": 544.0246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 380.8172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 6CFS",
      "code_information": [
        {
          "code": "3572191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 6MM",
      "code_information": [
        {
          "code": "3572195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 507,
          "minimum": 106.47,
          "maximum": 371.2254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 259.8578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRP MIC-KEY 14FR 1.5CM",
      "code_information": [
        {
          "code": "3572305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 516.1278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 35FR     125135",
      "code_information": [
        {
          "code": "3572307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 355.7028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 39FR     125139",
      "code_information": [
        {
          "code": "3572309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 355.7028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 41FR     125141",
      "code_information": [
        {
          "code": "3572311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 355.7028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 37FR LFT 125037",
      "code_information": [
        {
          "code": "3572315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 619,
          "minimum": 129.99,
          "maximum": 453.2318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 317.2623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BLAKEMORE 20 FR      9210",
      "code_information": [
        {
          "code": "3572344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2672,
          "minimum": 561.12,
          "maximum": 1956.4384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1369.5069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 5F 20\\\"     461412",
      "code_information": [
        {
          "code": "3572425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 6.5F 36\\\"   461438",
      "code_information": [
        {
          "code": "3572430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.3151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASOGASTRIC 8FR",
      "code_information": [
        {
          "code": "3572485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 18FR 20CC",
      "code_information": [
        {
          "code": "3572530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 237,
          "minimum": 49.77,
          "maximum": 173.5314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.5       86215",
      "code_information": [
        {
          "code": "3572860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.0       8621",
      "code_information": [
        {
          "code": "3572863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.0       86212",
      "code_information": [
        {
          "code": "3572865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.5       86213",
      "code_information": [
        {
          "code": "3572866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 8.0C      86216",
      "code_information": [
        {
          "code": "3572867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "3573037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "3573039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM",
      "code_information": [
        {
          "code": "3573355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 362.3658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 8MM",
      "code_information": [
        {
          "code": "3573357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 362.3658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF    SZs  DCTs",
      "code_information": [
        {
          "code": "3573530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 461,
          "minimum": 96.81,
          "maximum": 337.5442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 236.2809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FENESTRATED SZ 4TO10  CFN",
      "code_information": [
        {
          "code": "3573565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.8012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH #6   518035",
      "code_information": [
        {
          "code": "3573650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1495.5917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 8FR     8LPC",
      "code_information": [
        {
          "code": "3573714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 743,
          "minimum": 156.03,
          "maximum": 544.0246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 380.8172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,TRAC REINFO 6.0 86548",
      "code_information": [
        {
          "code": "3573730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 7.0     86550",
      "code_information": [
        {
          "code": "3573735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEEY PED",
      "code_information": [
        {
          "code": "3573845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 427,
          "minimum": 89.67,
          "maximum": 312.6494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.8546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 583,
          "minimum": 122.43,
          "maximum": 426.8726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 298.8108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 520,
          "minimum": 109.2,
          "maximum": 380.744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 266.5208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 0.8MM",
      "code_information": [
        {
          "code": "3573906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 256.7825,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3573910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 435,
          "minimum": 91.35,
          "maximum": 318.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 222.9549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF BLU 10.0MM",
      "code_information": [
        {
          "code": "3573911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 6.0MM",
      "code_information": [
        {
          "code": "3573914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 6.0MM",
      "code_information": [
        {
          "code": "3573915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1400,
          "minimum": 294,
          "maximum": 1025.08,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 717.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 8.0MM",
      "code_information": [
        {
          "code": "3573916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 576.6075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF 7.0MM",
      "code_information": [
        {
          "code": "3573920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 211.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 60A160",
      "code_information": [
        {
          "code": "3573926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 672,
          "minimum": 141.12,
          "maximum": 492.0384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 344.4269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 7MM",
      "code_information": [
        {
          "code": "3573937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.3922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE XL 7",
      "code_information": [
        {
          "code": "3573950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 576.6075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNDERPAD-CGLIDE XL 40X80 PK",
      "code_information": [
        {
          "code": "3574527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-D&C COLLECTION 23116",
      "code_information": [
        {
          "code": "3574563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.0675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-MITY-ONE MYSTIC   10058",
      "code_information": [
        {
          "code": "3574642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 661,
          "minimum": 138.81,
          "maximum": 483.9842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 338.7889,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI-REFLUX",
      "code_information": [
        {
          "code": "3574651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING TRACH    PMV007",
      "code_information": [
        {
          "code": "3574654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 879,
          "minimum": 184.59,
          "maximum": 643.6038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 450.5227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAX-BONE                  W31G",
      "code_information": [
        {
          "code": "3575105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.0534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER PK",
      "code_information": [
        {
          "code": "3575110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER XLPK",
      "code_information": [
        {
          "code": "3575115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 414,
          "minimum": 86.94,
          "maximum": 303.1308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.1916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-FOAM POSITIONING DISP",
      "code_information": [
        {
          "code": "3575122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MEDTRONIC ATRIAL    6492F",
      "code_information": [
        {
          "code": "3575572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK L/XL",
      "code_information": [
        {
          "code": "3575890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.5755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-THROMBIDISC TOPICAL HEMO",
      "code_information": [
        {
          "code": "3575891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.2353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD S/M",
      "code_information": [
        {
          "code": "3575892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.7041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD L/XL",
      "code_information": [
        {
          "code": "3575893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 518,
          "minimum": 108.78,
          "maximum": 379.2796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 265.4957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-LEG POSITIONER 111618",
      "code_information": [
        {
          "code": "3575894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.8012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK S/M",
      "code_information": [
        {
          "code": "3575895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRISTLET-PORTHOLE 6600021150",
      "code_information": [
        {
          "code": "3576870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.1897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH 442-2",
      "code_information": [
        {
          "code": "3576880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EXUDE HYDRO 6X6",
      "code_information": [
        {
          "code": "3580000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-OPTICELL AG+4X5",
      "code_information": [
        {
          "code": "3580001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 16FR",
      "code_information": [
        {
          "code": "3580005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST RT XS 8",
      "code_information": [
        {
          "code": "3580008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.3935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LT XS 8",
      "code_information": [
        {
          "code": "3580009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.58,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 EASY CAP II",
      "code_information": [
        {
          "code": "3580015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 171,
          "minimum": 35.91,
          "maximum": 125.2062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.6443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 14FR",
      "code_information": [
        {
          "code": "3580016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-NASAL L/R STANDARD",
      "code_information": [
        {
          "code": "3580017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 262,
          "minimum": 55.02,
          "maximum": 191.8364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 134.2855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT MED CLOSED",
      "code_information": [
        {
          "code": "3580023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,OVAL 5.5X13CM AR-8550COE",
      "code_information": [
        {
          "code": "3580025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 232.6932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3590000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1467,
          "minimum": 308.07,
          "maximum": 1074.1374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 751.8962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTROSTOMY 18FR   100-18",
      "code_information": [
        {
          "code": "3590008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 193.7401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BIOPSY BASIC         4380",
      "code_information": [
        {
          "code": "3590013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 301,
          "minimum": 63.21,
          "maximum": 220.3922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.2745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSAL 10FR  15642-001",
      "code_information": [
        {
          "code": "3590100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REPAIR ASH CATH      RPK01",
      "code_information": [
        {
          "code": "3590134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 693,
          "minimum": 145.53,
          "maximum": 507.4146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 355.1902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 185.0269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LMH LMH-1001",
      "code_information": [
        {
          "code": "3598009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1376.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 03.130.302",
      "code_information": [
        {
          "code": "3598013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-BLUE RHINO G2",
      "code_information": [
        {
          "code": "3598017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1462.2766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-STERLING 3.0X60X150",
      "code_information": [
        {
          "code": "3598023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1841,
          "minimum": 386.61,
          "maximum": 1347.9802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 943.5861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORGANIZER-7 DAY PILL 70069L",
      "code_information": [
        {
          "code": "3598024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.4405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I-KNIFE II 8065921502",
      "code_information": [
        {
          "code": "3598025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.7807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARDS-NEONATAL NOISE NON-MAG",
      "code_information": [
        {
          "code": "3598028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 215,
          "minimum": 45.15,
          "maximum": 157.423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.1961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE RCM-14815",
      "code_information": [
        {
          "code": "3598048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 839,
          "minimum": 176.19,
          "maximum": 614.3158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 430.0211,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPEN KNEE ABS-2001-OT",
      "code_information": [
        {
          "code": "3598069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2457.6293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE GEL",
      "code_information": [
        {
          "code": "3598076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACEMENT GEL",
      "code_information": [
        {
          "code": "3598077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER GEL",
      "code_information": [
        {
          "code": "3598078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-SAMPLE EXTENSION 1841-25",
      "code_information": [
        {
          "code": "3598081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-8MM ENT TUBE NVM5 2010480",
      "code_information": [
        {
          "code": "3598086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1173.2041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-MEGADYNE 10FT SMOKE",
      "code_information": [
        {
          "code": "3598109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 119.4218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MEGADYNE F/SMOKE",
      "code_information": [
        {
          "code": "3598110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 51.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ZIP PEN F/SMOKE EVAC",
      "code_information": [
        {
          "code": "3598111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 181.4392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER SO SPECTRUM SU",
      "code_information": [
        {
          "code": "3598112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 286.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER S1 SPECTRUM SU",
      "code_information": [
        {
          "code": "3598113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 286.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1603G",
      "code_information": [
        {
          "code": "3598114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 1661G",
      "code_information": [
        {
          "code": "3598115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MINIVAC MGVSFT10",
      "code_information": [
        {
          "code": "3598117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHTMAT-ULTRATHIN UA2550",
      "code_information": [
        {
          "code": "3598118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 818,
          "minimum": 171.78,
          "maximum": 598.9396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 419.2577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MEGADYN SPECULUM 23951",
      "code_information": [
        {
          "code": "3598134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.5331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-221C-0427",
      "code_information": [
        {
          "code": "3598154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 407.9818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLIDE-OCULAR KDB GLIDE",
      "code_information": [
        {
          "code": "3598156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROVU DISP PHB-03",
      "code_information": [
        {
          "code": "3598158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11119,
          "minimum": 2334.99,
          "maximum": 8141.3318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5698.9323,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BLUGRIGGS PERC DILATION",
      "code_information": [
        {
          "code": "3598159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2213,
          "minimum": 464.73,
          "maximum": 1620.3586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1134.251,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5X10 AR-8610TDC-01C",
      "code_information": [
        {
          "code": "3598172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1203.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-EGG 4.0MM 5820-015-040",
      "code_information": [
        {
          "code": "3598178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 2.0 6007-1200",
      "code_information": [
        {
          "code": "3598184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 497.6763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY SZ 8 8DCFS",
      "code_information": [
        {
          "code": "3598187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBT 7MM EMG ET 2010470",
      "code_information": [
        {
          "code": "3598201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1173.2041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LAPIPLASTY 40X11 SM-4011",
      "code_information": [
        {
          "code": "3598213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-MULTIPURPOSE TUBING",
      "code_information": [
        {
          "code": "3598219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-REINFUSION SB1E",
      "code_information": [
        {
          "code": "3598227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.3999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 3.2 HAMMER 702632",
      "code_information": [
        {
          "code": "3598233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4242,
          "minimum": 890.82,
          "maximum": 3105.9924,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2174.1947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK DS AR-8991DS",
      "code_information": [
        {
          "code": "3598238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 406.98,
          "maximum": 1419.0036,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 993.3025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 PLUS VCP317H",
      "code_information": [
        {
          "code": "3598242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 5.1254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM CSS-072-37-SQ",
      "code_information": [
        {
          "code": "3598257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 743.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-Z-FLO FLUID",
      "code_information": [
        {
          "code": "3598273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 441,
          "minimum": 92.61,
          "maximum": 322.9002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 226.0301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-25 G00896",
      "code_information": [
        {
          "code": "3598279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 193,
          "minimum": 40.53,
          "maximum": 141.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 98.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HIGH TORQUE 70-2001",
      "code_information": [
        {
          "code": "3598282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1378,
          "minimum": 289.38,
          "maximum": 1008.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 706.2801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP523H",
      "code_information": [
        {
          "code": "3598283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.8276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.3MM AR-7535",
      "code_information": [
        {
          "code": "3598289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 382.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYNGECTOMY SZ10 6132",
      "code_information": [
        {
          "code": "3598291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2343,
          "minimum": 492.03,
          "maximum": 1715.5446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1200.8812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUNCTURE 17FR/10MM 8141US",
      "code_information": [
        {
          "code": "3598296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2695,
          "minimum": 565.95,
          "maximum": 1973.279,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1381.2953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORCAPOD SUCTION BIOPSY",
      "code_information": [
        {
          "code": "3598300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 82.5189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-E-Z CLEAN 0016AM",
      "code_information": [
        {
          "code": "3598301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 22GX.75\\\"",
      "code_information": [
        {
          "code": "3598320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.1678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL 80M 04.038.380S",
      "code_information": [
        {
          "code": "3598333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4478,
          "minimum": 940.38,
          "maximum": 3278.7916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2295.1541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153204",
      "code_information": [
        {
          "code": "3598338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 SURGILON 8886195151",
      "code_information": [
        {
          "code": "3598362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.2399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 SURGILON 8886195141",
      "code_information": [
        {
          "code": "3598363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUB LIPO 3-TT-FILTRON",
      "code_information": [
        {
          "code": "3598384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2403,
          "minimum": 504.63,
          "maximum": 1759.4766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1231.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHEST-DRAIN 4050-100N",
      "code_information": [
        {
          "code": "3598393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.4816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEO TEE 1050810",
      "code_information": [
        {
          "code": "3598397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 147.6115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION SZ:8",
      "code_information": [
        {
          "code": "3598398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.8012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 10.5 CLR",
      "code_information": [
        {
          "code": "3598403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY L-WIRE 20115",
      "code_information": [
        {
          "code": "3598404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 362,
          "minimum": 76.02,
          "maximum": 265.0564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 185.5395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-LIGATING SURGITIE SGL-1",
      "code_information": [
        {
          "code": "3598405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 621,
          "minimum": 130.41,
          "maximum": 454.6962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 318.2873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 11 96\\\" Z880G",
      "code_information": [
        {
          "code": "3598407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-POWER 45MM FLEX PSEE45",
      "code_information": [
        {
          "code": "3598408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2062,
          "minimum": 433.02,
          "maximum": 1509.7964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1056.8575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 32FR 056132",
      "code_information": [
        {
          "code": "3598409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SOFSIK 2-0 18\\\" GS63M",
      "code_information": [
        {
          "code": "3598410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 116.8591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOSOF 5-0 SN-661",
      "code_information": [
        {
          "code": "3598412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1 G48",
      "code_information": [
        {
          "code": "3598413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 75.3434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0 3844G",
      "code_information": [
        {
          "code": "3598415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 714G",
      "code_information": [
        {
          "code": "3598417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD WARMING RAPID 24355",
      "code_information": [
        {
          "code": "3598418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 226.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTOLOGY 2.3MMX240CM",
      "code_information": [
        {
          "code": "3598419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 124.0347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY LONG 2.4MM E1450-6",
      "code_information": [
        {
          "code": "3598420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y527H",
      "code_information": [
        {
          "code": "3598424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-GRAVITY SPIKE FLUID MGMT",
      "code_information": [
        {
          "code": "3598425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.3922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEM SILVER 6.5X7",
      "code_information": [
        {
          "code": "3598426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 117.3717,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 20FR 5CC",
      "code_information": [
        {
          "code": "3598427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-J-TIP .035X145CM",
      "code_information": [
        {
          "code": "3598428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 169.1382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 30CC 16FR",
      "code_information": [
        {
          "code": "3598429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2 490T",
      "code_information": [
        {
          "code": "3598434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII BLADED CTB33",
      "code_information": [
        {
          "code": "3598436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM BLADELESS CTR03",
      "code_information": [
        {
          "code": "3598437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND 10FR DYNJWE1321A",
      "code_information": [
        {
          "code": "3598439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.8669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ULNAR NERVE 79-91100",
      "code_information": [
        {
          "code": "3598441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.3151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POWDER-HEMOSTAT AVITENE 1 GRAM",
      "code_information": [
        {
          "code": "3598442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1703,
          "minimum": 357.63,
          "maximum": 1246.9366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 872.8556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RADIAL ARTERY 20GX1.75\\\"",
      "code_information": [
        {
          "code": "3598444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 265,
          "minimum": 55.65,
          "maximum": 194.033,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 135.8231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL RHINO ROCKET LRG",
      "code_information": [
        {
          "code": "3598446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-FOREIGN BODY 60613",
      "code_information": [
        {
          "code": "3598447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 663,
          "minimum": 139.23,
          "maximum": 485.4486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 339.814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 24FR 056124",
      "code_information": [
        {
          "code": "3598448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-HYDROFERA 6X6 HB6614",
      "code_information": [
        {
          "code": "3598449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.7337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SMALL WIDE",
      "code_information": [
        {
          "code": "3598450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 112.2463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARYNGECTOMY SZ6 6LGT",
      "code_information": [
        {
          "code": "3598451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 457,
          "minimum": 95.97,
          "maximum": 334.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 234.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X285MM 703586",
      "code_information": [
        {
          "code": "3598458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 290.0976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 290.0976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 18FR",
      "code_information": [
        {
          "code": "3598463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 502.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 576.6075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATFORM-GELPOINT PATH CNB11",
      "code_information": [
        {
          "code": "3598471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2529.8974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VINYL CONNECTING G02791",
      "code_information": [
        {
          "code": "3598473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 118.3967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRUIT, CROSS VENT 80011",
      "code_information": [
        {
          "code": "3598474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 323,
          "minimum": 67.83,
          "maximum": 236.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.5504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR, NEO W/MASK",
      "code_information": [
        {
          "code": "3598475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 342,
          "minimum": 71.82,
          "maximum": 250.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 175.2887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3598478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 399.2687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC #1 48G",
      "code_information": [
        {
          "code": "3598479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STEM 222-496100",
      "code_information": [
        {
          "code": "3598480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5912,
          "minimum": 1241.52,
          "maximum": 4328.7664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3030.1365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRIP-PLATINUM MS04R-IP10X-0JH",
      "code_information": [
        {
          "code": "3598481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4118,
          "minimum": 864.78,
          "maximum": 3015.1996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2110.6397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-ENDOCAPSULE 10 MAJ2027",
      "code_information": [
        {
          "code": "3598483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3003,
          "minimum": 630.63,
          "maximum": 2198.7966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1539.1576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-10G/7.75\\\" 0306-810-000",
      "code_information": [
        {
          "code": "3598484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 724,
          "minimum": 152.04,
          "maximum": 530.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 371.079,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77420",
      "code_information": [
        {
          "code": "3598485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 584,
          "minimum": 122.64,
          "maximum": 427.6048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 299.3234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/SUPPORT #6",
      "code_information": [
        {
          "code": "3598487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 784,
          "minimum": 164.64,
          "maximum": 574.0448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 401.8314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST 4050-100N",
      "code_information": [
        {
          "code": "3598488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 361.8532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-GONIOTOMY TRABEX 600042",
      "code_information": [
        {
          "code": "3598489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3014,
          "minimum": 632.94,
          "maximum": 2206.8508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1544.7956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-STRAIGHT JAW NSLX137S",
      "code_information": [
        {
          "code": "3598493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2542,
          "minimum": 533.82,
          "maximum": 1861.2524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1302.8767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW NSLX137C",
      "code_information": [
        {
          "code": "3598494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2637,
          "minimum": 553.77,
          "maximum": 1930.8114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1351.568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW 25CM NSLX125C",
      "code_information": [
        {
          "code": "3598495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2676,
          "minimum": 561.96,
          "maximum": 1959.3672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1371.557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JADA POSTPARTUM",
      "code_information": [
        {
          "code": "3598497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5844,
          "minimum": 1227.24,
          "maximum": 4278.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2995.2838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA G PROCEDURAL PUG",
      "code_information": [
        {
          "code": "3598498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9014,
          "minimum": 1892.94,
          "maximum": 6600.0508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4620.0356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-4MM/SHORT 1149.8052",
      "code_information": [
        {
          "code": "3598502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1307.4895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN",
      "code_information": [
        {
          "code": "3598508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN",
      "code_information": [
        {
          "code": "3598509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1055,
          "minimum": 221.55,
          "maximum": 772.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 540.7297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94975",
      "code_information": [
        {
          "code": "3598515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1030,
          "minimum": 216.3,
          "maximum": 754.166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 527.9162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYN W/EL SZ10 6136",
      "code_information": [
        {
          "code": "3598520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4004,
          "minimum": 840.84,
          "maximum": 2931.7288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2052.2102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.4X100/LG AGK10100",
      "code_information": [
        {
          "code": "3598521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 226.5427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X120MM 45302001",
      "code_information": [
        {
          "code": "3598524",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 201.9408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNIT-TI-KNOT QUICK LOAD 030510",
      "code_information": [
        {
          "code": "3598527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PICO 14 WOUND 15X30CM",
      "code_information": [
        {
          "code": "3598530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1724,
          "minimum": 362.04,
          "maximum": 1262.3128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 883.619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1590,
          "minimum": 333.9,
          "maximum": 1164.198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 814.9386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY STANDARD 7607",
      "code_information": [
        {
          "code": "3598534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1347,
          "minimum": 282.87,
          "maximum": 986.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 690.3914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND XTRASORB 6X9",
      "code_information": [
        {
          "code": "3598535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1828,
          "minimum": 383.88,
          "maximum": 1338.4616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 936.9231,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS SELECT",
      "code_information": [
        {
          "code": "3598538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY",
      "code_information": [
        {
          "code": "3598539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1496,
          "minimum": 314.16,
          "maximum": 1095.3712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 766.7598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LK/MD 3.1X328 705077",
      "code_information": [
        {
          "code": "3598547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1526,
          "minimum": 320.46,
          "maximum": 1117.3372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 782.136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E-CATH PLUS 251285-41E",
      "code_information": [
        {
          "code": "3598551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-OVAL CUP BIOPSY SINGLE",
      "code_information": [
        {
          "code": "3598561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 299.8359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEATED W/GAS FILTER",
      "code_information": [
        {
          "code": "3598562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 652,
          "minimum": 136.92,
          "maximum": 477.3944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 334.1761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-10X360/RT/130* 3430-0360S",
      "code_information": [
        {
          "code": "3598565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6277,
          "minimum": 1318.17,
          "maximum": 4596.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3217.2136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3598587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X65MM 03.130.201",
      "code_information": [
        {
          "code": "3598592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1114,
          "minimum": 233.94,
          "maximum": 815.6708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 570.9696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-AIRSEAL CANN 8MM IAS8-DV",
      "code_information": [
        {
          "code": "3598593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 575.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTERD FURCATED ASM-EVAC",
      "code_information": [
        {
          "code": "3598594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 575.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS + MAP152",
      "code_information": [
        {
          "code": "3598601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.5331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRIVE T6 VARIAX2 705132",
      "code_information": [
        {
          "code": "3598602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2210,
          "minimum": 464.1,
          "maximum": 1618.162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1132.7134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREW T7 AO 45-27015",
      "code_information": [
        {
          "code": "3598609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1540,
          "minimum": 323.4,
          "maximum": 1127.588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 789.3116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROXIMATE PROCEDURE PPH03",
      "code_information": [
        {
          "code": "3598617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2668,
          "minimum": 560.28,
          "maximum": 1953.5096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1367.4567,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X7MM 60-16007",
      "code_information": [
        {
          "code": "3598624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1349,
          "minimum": 283.29,
          "maximum": 987.7378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 691.4165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.9X115/35MM 92-19135",
      "code_information": [
        {
          "code": "3598625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2047,
          "minimum": 429.87,
          "maximum": 1498.8134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1049.1694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 134.798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-EDIPURAL 17GX3.5 BUPIV",
      "code_information": [
        {
          "code": "3598647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 362,
          "minimum": 76.02,
          "maximum": 265.0564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 185.5395,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 0.3MM DWD055",
      "code_information": [
        {
          "code": "3598653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1389,
          "minimum": 291.69,
          "maximum": 1017.0258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 711.9181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #2",
      "code_information": [
        {
          "code": "3598662",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.3831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDICLE ACCESS 624.027S",
      "code_information": [
        {
          "code": "3598668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2313.093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISTAL DUODENOVIDEOSCOPE",
      "code_information": [
        {
          "code": "3598674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3598678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 974,
          "minimum": 204.54,
          "maximum": 713.1628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 499.214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 24FR 77424",
      "code_information": [
        {
          "code": "3598679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 486,
          "minimum": 102.06,
          "maximum": 355.8492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 249.0944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X13MM AR-300-B001",
      "code_information": [
        {
          "code": "3598688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2343,
          "minimum": 492.03,
          "maximum": 1715.5446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1200.8812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X19.5MM AR-300-B201",
      "code_information": [
        {
          "code": "3598689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2396,
          "minimum": 503.16,
          "maximum": 1754.3512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1228.0458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8710H",
      "code_information": [
        {
          "code": "3598695",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8725H",
      "code_information": [
        {
          "code": "3598696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 385,
          "minimum": 80.85,
          "maximum": 281.897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 197.3279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8806H",
      "code_information": [
        {
          "code": "3598697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8718H",
      "code_information": [
        {
          "code": "3598698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 132.2353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8714H",
      "code_information": [
        {
          "code": "3598699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 215,
          "minimum": 45.15,
          "maximum": 157.423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 110.1961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W SPPRT MXPRSK05",
      "code_information": [
        {
          "code": "3598700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.3831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-BENSTON 260CM/.035\\\"",
      "code_information": [
        {
          "code": "3598702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 108.6585,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/ SUPPORT #3",
      "code_information": [
        {
          "code": "3598704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 424.3831,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-LT 130°/10X420 3530-0420S",
      "code_information": [
        {
          "code": "3598705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6277,
          "minimum": 1318.17,
          "maximum": 4596.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3217.2136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-XI 45MM 480445",
      "code_information": [
        {
          "code": "3598714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3242,
          "minimum": 680.82,
          "maximum": 2373.7924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1661.6547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-MUSTANG 7.0X20X135CM",
      "code_information": [
        {
          "code": "3598729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 698.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT,ACTIVE ANKLE HEEL-LOCK",
      "code_information": [
        {
          "code": "3598758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 464,
          "minimum": 97.44,
          "maximum": 339.7408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 237.8186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Suture-7-0 Prolene Blue 8704H",
      "code_information": [
        {
          "code": "3598759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.8983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR,SURGICEL 3123SPEA",
      "code_information": [
        {
          "code": "3598761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 165.0379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP ESREC",
      "code_information": [
        {
          "code": "3598782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 3.0X2.1 45-30005",
      "code_information": [
        {
          "code": "3598799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1849,
          "minimum": 388.29,
          "maximum": 1353.8378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 947.6865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAC 425840405",
      "code_information": [
        {
          "code": "3598801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.6694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-8737-37",
      "code_information": [
        {
          "code": "3598812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE,.045\\\" THD AR-8737-05",
      "code_information": [
        {
          "code": "3598815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.7369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO 2.0MM DC6106",
      "code_information": [
        {
          "code": "3598843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 894.3823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.5X150MM 58862515",
      "code_information": [
        {
          "code": "3598844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM DSDS1011",
      "code_information": [
        {
          "code": "3598845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.5MM DSDS0025",
      "code_information": [
        {
          "code": "3598846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 976.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.0MM DSDS0030",
      "code_information": [
        {
          "code": "3598853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 976.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR SHEEHY 510-131C",
      "code_information": [
        {
          "code": "3598870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 105.0707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR PAPERELLA 510-043C",
      "code_information": [
        {
          "code": "3598871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 112.7588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F X-FIT 60-80323",
      "code_information": [
        {
          "code": "3598874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 743.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F 1.7MM 60-80317",
      "code_information": [
        {
          "code": "3598875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 743.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EAR-SPEEDIWICK 15MM OT-5201-50",
      "code_information": [
        {
          "code": "3598882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 15CM APYX-15-TP",
      "code_information": [
        {
          "code": "3598955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3007,
          "minimum": 631.47,
          "maximum": 2201.7254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1541.2078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERIOTOMY",
      "code_information": [
        {
          "code": "3598957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 452.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/46-62\\\" 1143PP",
      "code_information": [
        {
          "code": "3598975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 58.9421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 6.0 BIPOLAR",
      "code_information": [
        {
          "code": "3598997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2604,
          "minimum": 546.84,
          "maximum": 1906.6488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1334.6542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 004025",
      "code_information": [
        {
          "code": "3599029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.58,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-WIGGLE OPTIFLOW JR 2 M",
      "code_information": [
        {
          "code": "3599030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND HANZ RT LG",
      "code_information": [
        {
          "code": "3599041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 494,
          "minimum": 103.74,
          "maximum": 361.7068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 253.1948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.65MM MD 45303065",
      "code_information": [
        {
          "code": "3599049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.55MM MD 45303055",
      "code_information": [
        {
          "code": "3599050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8305H",
      "code_information": [
        {
          "code": "3599073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-S-CURVE URETH DIL G32789",
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        {
          "code": "3599074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 427.56,
          "maximum": 1490.7592,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5x57MM 03.130.211",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
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        {
          "code": "3599096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002352",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002351",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.3MM CSS-040-23",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-NAIL 3MM 4150004025",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-FULL VIP1137430",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 56.49,
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          "payers_information": [
            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 59.64,
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #4",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-HINGED KNEE LG 11-0672-4",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "maximum": 638.4784,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-PROCESSOR DEPTH Z179994",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "BIT-DRILL 3.2X230/200MM 315.93",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 1336.9972,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CERCLAGE STR/LG AR-7822",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-INS MID/HINDFOOT FFSP1530",
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        },
        {
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        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SET RENOVARP GIS-30",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
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    },
    {
      "description": "DRILL-QC 2.5/135X45 03.133.102",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SYSTEM-100.783+/3H 954-0035",
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        },
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          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PARACENTESIS GIS-31",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-MALE EXT PWM-030 PUREWICK",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 49.98,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 2 1/2\\\"",
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        {
          "code": "3599298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 3\\\"",
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        {
          "code": "3599299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-PLANTAR KERATOSIS WOMENS",
      "code_information": [
        {
          "code": "3599300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" SMALL",
      "code_information": [
        {
          "code": "3599306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" MEDIUM",
      "code_information": [
        {
          "code": "3599307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" LARGE",
      "code_information": [
        {
          "code": "3599308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE DOUBLE",
      "code_information": [
        {
          "code": "3599309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE SINGLE",
      "code_information": [
        {
          "code": "3599310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE LEFT",
      "code_information": [
        {
          "code": "3599311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.2038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE RIGHT",
      "code_information": [
        {
          "code": "3599312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.2038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 25GX5”",
      "code_information": [
        {
          "code": "3599313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 251,
          "minimum": 52.71,
          "maximum": 183.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 128.6475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3599314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1037,
          "minimum": 217.77,
          "maximum": 759.2914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 531.504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXYGENATOR-PERFUSION 050715",
      "code_information": [
        {
          "code": "3599315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1812,
          "minimum": 380.52,
          "maximum": 1326.7464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 928.7225,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-Y TYPE PERFUSION 10004",
      "code_information": [
        {
          "code": "3599362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.6161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 19G X 1.5\\\"CT",
      "code_information": [
        {
          "code": "3599369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.0424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM TUBING 8H23R12",
      "code_information": [
        {
          "code": "3599370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2383,
          "minimum": 500.43,
          "maximum": 1744.8326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1221.3828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.7/125MM 03.133.105",
      "code_information": [
        {
          "code": "3599378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1325,
          "minimum": 278.25,
          "maximum": 970.165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 679.1155,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-PIECE-OXYGEN MONITOR",
      "code_information": [
        {
          "code": "3599381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.6411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 5ML GIS-55",
      "code_information": [
        {
          "code": "3599412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-FINGER XL A8685",
      "code_information": [
        {
          "code": "3599413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 112.7588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY 040-300",
      "code_information": [
        {
          "code": "3599414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.5755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RET 5MM/155CM FB-231D.A",
      "code_information": [
        {
          "code": "3599417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/135X45 03.133.106",
      "code_information": [
        {
          "code": "3599424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1497,
          "minimum": 314.37,
          "maximum": 1096.1034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 767.2724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL N8 PROCESSOR DUALN8",
      "code_information": [
        {
          "code": "3599512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62546,
          "minimum": 13134.66,
          "maximum": 45796.1812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32057.3268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0 EPM8703",
      "code_information": [
        {
          "code": "3599513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 901,
          "minimum": 189.21,
          "maximum": 659.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 461.7985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.002",
      "code_information": [
        {
          "code": "3599527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 944,
          "minimum": 198.24,
          "maximum": 691.1968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 483.8378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOYSTICK-RED 5MM 03.211.454",
      "code_information": [
        {
          "code": "3599531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2911,
          "minimum": 611.31,
          "maximum": 2131.4342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1492.0039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IABC 40CC 7FR IMU7F-40",
      "code_information": [
        {
          "code": "3599539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5359,
          "minimum": 1125.39,
          "maximum": 3923.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2746.7019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-SD 2MM T6 313.843.V",
      "code_information": [
        {
          "code": "3599548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1853,
          "minimum": 389.13,
          "maximum": 1356.7666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 949.7366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIX 1.1MM DC4212",
      "code_information": [
        {
          "code": "3599593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 604.7972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 70MM",
      "code_information": [
        {
          "code": "3599601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 100MM",
      "code_information": [
        {
          "code": "3599602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE SMALL",
      "code_information": [
        {
          "code": "3599607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.1569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE MEDIUM",
      "code_information": [
        {
          "code": "3599608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.1569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE LARGE",
      "code_information": [
        {
          "code": "3599609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.1569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE X-LARGE",
      "code_information": [
        {
          "code": "3599610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.1569,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 3520",
      "code_information": [
        {
          "code": "3599611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4030",
      "code_information": [
        {
          "code": "3599612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4540",
      "code_information": [
        {
          "code": "3599613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5040",
      "code_information": [
        {
          "code": "3599614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.3183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5550",
      "code_information": [
        {
          "code": "3599615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 71.2431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 35-40CM",
      "code_information": [
        {
          "code": "3599617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 293,
          "minimum": 61.53,
          "maximum": 214.5346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 150.1742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 40-45CM",
      "code_information": [
        {
          "code": "3599618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 293,
          "minimum": 61.53,
          "maximum": 214.5346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 150.1742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE CVD AC-20055390",
      "code_information": [
        {
          "code": "3599638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1368,
          "minimum": 287.28,
          "maximum": 1001.6496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 701.1547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE STRAIGHT",
      "code_information": [
        {
          "code": "3599639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1369,
          "minimum": 287.49,
          "maximum": 1002.3818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 701.6673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .315\\\" NAR 200138107S",
      "code_information": [
        {
          "code": "3599664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .50\\\" WIDE 200138108S",
      "code_information": [
        {
          "code": "3599666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-BONE SCREW IB200051",
      "code_information": [
        {
          "code": "3599670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1584,
          "minimum": 332.64,
          "maximum": 1159.8048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 811.8634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDES-PT SPECIFIC PROPINF",
      "code_information": [
        {
          "code": "3599671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7311,
          "minimum": 1535.31,
          "maximum": 5353.1142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3747.1799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 2.4MM 200072",
      "code_information": [
        {
          "code": "3599672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 287.5349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CORNER 4.8MM 33600048",
      "code_information": [
        {
          "code": "3599673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2020,
          "minimum": 424.2,
          "maximum": 1479.044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1035.3308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACID-5% ACETIC 9045052",
      "code_information": [
        {
          "code": "3599696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL CARE DUOCARE MDS604DC",
      "code_information": [
        {
          "code": "3599708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.2823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3599751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.8276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-INTERSEPT 6031",
      "code_information": [
        {
          "code": "3599752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X1/4X1/4 Y 6036",
      "code_information": [
        {
          "code": "3599753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/2X3/8X3/8 6040",
      "code_information": [
        {
          "code": "3599754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 33.8276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PERFUSE 1/4\\\" 10007",
      "code_information": [
        {
          "code": "3599756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/M P01-900-1703",
      "code_information": [
        {
          "code": "3599770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1386.4207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH 82-1516",
      "code_information": [
        {
          "code": "3599774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1505,
          "minimum": 316.05,
          "maximum": 1101.961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 771.3727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOPRO-VASOVIEW 2 VEIN",
      "code_information": [
        {
          "code": "3599778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6789,
          "minimum": 1425.69,
          "maximum": 4970.9058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3479.6341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 5F 20\\\"",
      "code_information": [
        {
          "code": "3599779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 6.5F 36\\\"",
      "code_information": [
        {
          "code": "3599780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 40.4907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UNIVERSAL PALM MEDIUM",
      "code_information": [
        {
          "code": "3599787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 17GX4.5\\\"",
      "code_information": [
        {
          "code": "3599788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 118.3967,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPACER IN-LINE 42-RTC24-VP",
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        {
          "code": "3599789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.2289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRIMARY DUOVENT 1424828",
      "code_information": [
        {
          "code": "3599790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.1678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-PED ANES W/FILTER",
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        {
          "code": "3599791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 143,
          "minimum": 30.03,
          "maximum": 104.7046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.2932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 45MM",
      "code_information": [
        {
          "code": "3599808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 603.54,
          "maximum": 2104.3428,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1473.04,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 60MM",
      "code_information": [
        {
          "code": "3599809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3133,
          "minimum": 657.93,
          "maximum": 2293.9826,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1605.7878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
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        {
          "code": "3599818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 77.28,
          "maximum": 269.4496,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 188.6147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 190.6649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ATERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 130.6977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 10CM SHORT",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 8CM SHORT",
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        {
          "code": "3599882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 49.2038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-LP 2MMX4CM RBYLP0204",
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        {
          "code": "3599885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4457,
          "minimum": 935.97,
          "maximum": 3263.4154,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2284.3908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.1X70 KWIRE 03.130.200",
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        {
          "code": "3599922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5X7 STD AR-7350TD",
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        {
          "code": "3599951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 567.8943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY G 18FR 2.7",
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        {
          "code": "3599960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 502.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING DISP FG-600U",
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        {
          "code": "3600018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 782,
          "minimum": 164.22,
          "maximum": 572.5804,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 400.8063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT 10012",
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        {
          "code": "3600074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 116.3466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/36 7413",
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        {
          "code": "3600119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 304.92,
          "maximum": 1063.1544,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 744.2081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PROVOX XTRAFLOW HME",
      "code_information": [
        {
          "code": "3600120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 10/36",
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        {
          "code": "3600121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 743.6955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORA/PARA 6FRTAPS-6F-12PT",
      "code_information": [
        {
          "code": "3600163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 835,
          "minimum": 175.35,
          "maximum": 611.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 427.9709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.3CM",
      "code_information": [
        {
          "code": "3600165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 127.05,
          "maximum": 442.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 310.0867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNOTOMY 046-367",
      "code_information": [
        {
          "code": "3600166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 497.6763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-SELF LOCKING 4933-0-802",
      "code_information": [
        {
          "code": "3600214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 96.3575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH14 050179",
      "code_information": [
        {
          "code": "3600219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 497.6763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R501-26",
      "code_information": [
        {
          "code": "3600220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 169.1382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL XS EVF1XSLA",
      "code_information": [
        {
          "code": "3600221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 253,
          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.6726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL S-M EVF1MSLA",
      "code_information": [
        {
          "code": "3600222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 253,
          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.6726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL L EVF1LSLA",
      "code_information": [
        {
          "code": "3600223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.6726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SMLSL",
      "code_information": [
        {
          "code": "3600229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 121.9845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 8 5 165808",
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        {
          "code": "3600233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 28.7022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SZ 0 VLOCM2146",
      "code_information": [
        {
          "code": "3600255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 390,
          "minimum": 81.9,
          "maximum": 285.558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 199.8906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 BARBED VLOCL0615",
      "code_information": [
        {
          "code": "3600256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 299.8359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X285MM 703583",
      "code_information": [
        {
          "code": "3600270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 186.052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R502-15",
      "code_information": [
        {
          "code": "3600272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT AR-11114",
      "code_information": [
        {
          "code": "3600273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.4861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO 125MM AR-3210-0051",
      "code_information": [
        {
          "code": "3600300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR,SUCTION 8MM 480299",
      "code_information": [
        {
          "code": "3600302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1868,
          "minimum": 392.28,
          "maximum": 1367.7496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 957.4247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-2.3MM INLINE DRILL MOUTH",
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        {
          "code": "3600308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2463,
          "minimum": 517.23,
          "maximum": 1803.4086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1262.386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SPIRAL 7000AAO",
      "code_information": [
        {
          "code": "3600310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ONESTEP 5F OSC-5F-12PT/C",
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        {
          "code": "3600311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 468,
          "minimum": 98.28,
          "maximum": 342.6696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 239.8687,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NASAL ETOC2 ADT",
      "code_information": [
        {
          "code": "3600315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 277,
          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.9736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48MM EZOUT 7812-048-001K",
      "code_information": [
        {
          "code": "3600316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2602.1656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-50MM EZOUT 7812-050-001K",
      "code_information": [
        {
          "code": "3600317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2602.1656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC/SAG 5.5 2296-023-412",
      "code_information": [
        {
          "code": "3600318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 193.7401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FAT TRANS VIALITY-1400",
      "code_information": [
        {
          "code": "3600331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1734.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3600343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL 3.5/2.5 AR-8943-14",
      "code_information": [
        {
          "code": "3600344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3998,
          "minimum": 839.58,
          "maximum": 2927.3356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2049.1349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 MONOTEX T8623",
      "code_information": [
        {
          "code": "3600351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.2495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-VISION SUCTION PROBE",
      "code_information": [
        {
          "code": "3600353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-VISION PROBE ION 490127",
      "code_information": [
        {
          "code": "3600354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 168.6257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 19G BIOPSY",
      "code_information": [
        {
          "code": "3600355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 21G BIOPSY",
      "code_information": [
        {
          "code": "3600356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 23G BIOPSY",
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        {
          "code": "3600357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 14-16FR",
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        {
          "code": "3600358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.2321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-ION SWIVEL",
      "code_information": [
        {
          "code": "3600359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 696.0293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 5X356/126MM 03.008.008",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 403.41,
          "maximum": 1406.5562,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROC 2.3X230 P99-194-2323",
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        {
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 514.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3600412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 698.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUMIDIFIER-CPAP HC325S",
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        {
          "code": "3600428",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE M001141006",
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        {
          "code": "3600430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1293,
          "minimum": 271.53,
          "maximum": 946.7346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 662.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-2-2.7MM 706200",
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        {
          "code": "3600436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 722.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-8MM/SD LORD 1088-43-008",
      "code_information": [
        {
          "code": "3600449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2024.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-6MM/SD PARA 108843106",
      "code_information": [
        {
          "code": "3600452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2024.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER FLX 4150016000",
      "code_information": [
        {
          "code": "3600467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4998,
          "minimum": 1049.58,
          "maximum": 3659.5356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2561.6749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-9X250 STP 4150002090",
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        {
          "code": "3600471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1114.7745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-FETAL C-SECTION",
      "code_information": [
        {
          "code": "3600474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2876.887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-BAND POLY CFI-733",
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        {
          "code": "3600493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 39.9781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PUMP 8\\\" AR-6411",
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        {
          "code": "3600498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC OUTFLOW AR-6435",
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        {
          "code": "3600499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 157.92,
          "maximum": 550.6144,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 385.4301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY M00516071",
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        {
          "code": "3600502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VEIN HARVEST VASOVIEW",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 309.96,
          "maximum": 1080.7272,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURSPLEX DART300 NASAL",
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        {
          "code": "3600506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.9781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURAPLEX DART-REACH600",
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        {
          "code": "3600507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY O40-403",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 4.6X340 P99-110-4634",
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        {
          "code": "3600519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1434.5995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 11X200 4922-8-200",
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        {
          "code": "3600545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 375.06,
          "maximum": 1307.7092,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 915.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HEMOCON PERF 020271801",
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        {
          "code": "3600548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 842,
          "minimum": 176.82,
          "maximum": 616.5124,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 431.5587,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-SINGLE NEOPRENE M8138",
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        {
          "code": "3600550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION ADULT",
      "code_information": [
        {
          "code": "3600551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION PED",
      "code_information": [
        {
          "code": "3600552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383592",
      "code_information": [
        {
          "code": "3600553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 63.0424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-EAR DISP 4015",
      "code_information": [
        {
          "code": "3600557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 154.7871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG STRT AR-7821",
      "code_information": [
        {
          "code": "3600561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 851.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 10FL AR-9280NOT",
      "code_information": [
        {
          "code": "3600562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 567.8943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-NANO 2.8X11 AR-9280NSR",
      "code_information": [
        {
          "code": "3600563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 567.8943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-HP EVAC 70 E1CA5874-01",
      "code_information": [
        {
          "code": "3600565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2197,
          "minimum": 461.37,
          "maximum": 1608.6434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1126.0504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-EVAC 70 EICA5872-01",
      "code_information": [
        {
          "code": "3600567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2097,
          "minimum": 440.37,
          "maximum": 1535.4234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1074.7964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE XP EICA8872-01",
      "code_information": [
        {
          "code": "3600568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2093,
          "minimum": 439.53,
          "maximum": 1532.4946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1072.7462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PURPLE",
      "code_information": [
        {
          "code": "3600570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY PURPLE",
      "code_information": [
        {
          "code": "3600571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PINK/RED",
      "code_information": [
        {
          "code": "3600574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY YELLOW",
      "code_information": [
        {
          "code": "3600575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY WHITE",
      "code_information": [
        {
          "code": "3600576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION WHITE",
      "code_information": [
        {
          "code": "3600577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION BLUE",
      "code_information": [
        {
          "code": "3600579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION ORANGE",
      "code_information": [
        {
          "code": "3600580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY ORANGE",
      "code_information": [
        {
          "code": "3600581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION GREEN",
      "code_information": [
        {
          "code": "3600582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GUIDE 95CM/9FR STRT",
      "code_information": [
        {
          "code": "3600599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 976.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 16MM P45-914-0001",
      "code_information": [
        {
          "code": "3600607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-XL 10MM HEX P45-941-0001",
      "code_information": [
        {
          "code": "3600609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 349.0397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT P45-170-1000",
      "code_information": [
        {
          "code": "3600610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3462.7202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MEASURE STOMA MIC-KEY",
      "code_information": [
        {
          "code": "3600617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 46.6411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENTERAL FEEDING LITE",
      "code_information": [
        {
          "code": "3600618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 70.7305,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-FARREL ENTERAL W BAG",
      "code_information": [
        {
          "code": "3600619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 64.58,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.7MM AR-7511",
      "code_information": [
        {
          "code": "3600664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 WHITE 48360W",
      "code_information": [
        {
          "code": "3600665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 830.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLUE 48360B",
      "code_information": [
        {
          "code": "3600666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 830.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 GREEN 48360G",
      "code_information": [
        {
          "code": "3600667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 830.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLACK 48360T",
      "code_information": [
        {
          "code": "3600668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 830.8273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-PORTABLE DEVILBISS",
      "code_information": [
        {
          "code": "3600669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2011,
          "minimum": 422.31,
          "maximum": 1472.4542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1030.7179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WATER-STERILE INHALATION 500ML",
      "code_information": [
        {
          "code": "3600670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-14FR SU130-1239",
      "code_information": [
        {
          "code": "3600671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2016,
          "minimum": 423.36,
          "maximum": 1476.1152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1033.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-16FR SU130-1240",
      "code_information": [
        {
          "code": "3600672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2016,
          "minimum": 423.36,
          "maximum": 1476.1152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1033.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X185MM 2351-4218S",
      "code_information": [
        {
          "code": "3600681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 666.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 1.7MM DSDS0017",
      "code_information": [
        {
          "code": "3600688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 976.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2MM DSDS0020",
      "code_information": [
        {
          "code": "3600689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 976.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3600708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 534.0667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.6X150MM AR-8741-16",
      "code_information": [
        {
          "code": "3600710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 314.6996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,-TR 2X8MM AR-300-B002",
      "code_information": [
        {
          "code": "3600711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1264.4362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X3.5MM AR-8741-14",
      "code_information": [
        {
          "code": "3600715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 312.1369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION AR-200",
      "code_information": [
        {
          "code": "3600717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 201.9408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-3.7MM DRILL AR-2272",
      "code_information": [
        {
          "code": "3600719",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1425,
          "minimum": 299.25,
          "maximum": 1043.385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 730.3695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO POLY M-L 51114V",
      "code_information": [
        {
          "code": "3600722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.9781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CADD PCA 108” 21-7391-24",
      "code_information": [
        {
          "code": "3600723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 86.1067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.102",
      "code_information": [
        {
          "code": "3600736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 X806H",
      "code_information": [
        {
          "code": "3600739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.2038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN PVC 24FR",
      "code_information": [
        {
          "code": "3600749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANCHOR-ENTUIT SUTURE G35562",
      "code_information": [
        {
          "code": "3600750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1342,
          "minimum": 281.82,
          "maximum": 982.6124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 687.8287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT FEEDINGTUBE G3561",
      "code_information": [
        {
          "code": "3600751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 397.731,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LEAD-CATH 4FR 38 383069",
      "code_information": [
        {
          "code": "3600757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-NITINOL 2.0MM",
      "code_information": [
        {
          "code": "3600759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6MM MXM-072-16",
      "code_information": [
        {
          "code": "3600767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 922.0595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6 MXM-072-ISO-16",
      "code_information": [
        {
          "code": "3600768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 922.0595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RCC RMH-T015S",
      "code_information": [
        {
          "code": "3600773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 463.3362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXOFIN FUSION EF70430",
      "code_information": [
        {
          "code": "3600781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 976,
          "minimum": 204.96,
          "maximum": 714.6272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 500.239,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 MONOTEX FS-2 T8665",
      "code_information": [
        {
          "code": "3600782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.4045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA",
      "code_information": [
        {
          "code": "3600783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "XTRAFLANGE-PROVOX 20 FR 7276",
      "code_information": [
        {
          "code": "3600784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20 FR 6MM 8277",
      "code_information": [
        {
          "code": "3600785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1951,
          "minimum": 409.71,
          "maximum": 1428.5222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 999.9655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2006-NS",
      "code_information": [
        {
          "code": "3600786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1495.5917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-NS",
      "code_information": [
        {
          "code": "3600787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1495.5917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-LF",
      "code_information": [
        {
          "code": "3600788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1495.5917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE 4.2X130 2351-4213S",
      "code_information": [
        {
          "code": "3600791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 666.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-LOCK 4.2X360 2351-4236S",
      "code_information": [
        {
          "code": "3600792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 666.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-CARDIOTOMY EL400",
      "code_information": [
        {
          "code": "3600858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 579,
          "minimum": 121.59,
          "maximum": 423.9438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 296.7607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 34CC LINEAR",
      "code_information": [
        {
          "code": "3600866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4523,
          "minimum": 949.83,
          "maximum": 3311.7406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2318.2184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 40CC MEGA 0",
      "code_information": [
        {
          "code": "3600867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4905,
          "minimum": 1030.05,
          "maximum": 3591.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2514.0087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 50CC MEGA 0",
      "code_information": [
        {
          "code": "3600868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4905,
          "minimum": 1030.05,
          "maximum": 3591.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2514.0087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-8\\\" THD AR-8967KT",
      "code_information": [
        {
          "code": "3600879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1 LMA",
      "code_information": [
        {
          "code": "3600899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 10' 251010J",
      "code_information": [
        {
          "code": "3600900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-STR 4MM P1-AU511",
      "code_information": [
        {
          "code": "3600906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7067,
          "minimum": 1484.07,
          "maximum": 5174.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3622.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1.5 LMA",
      "code_information": [
        {
          "code": "3600907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 3 LMA",
      "code_information": [
        {
          "code": "3600908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 5 LMA",
      "code_information": [
        {
          "code": "3600909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 2 LMA",
      "code_information": [
        {
          "code": "3600910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS MED TRACTION",
      "code_information": [
        {
          "code": "3600912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS LG TRACTION",
      "code_information": [
        {
          "code": "3600913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS SM TRACTION",
      "code_information": [
        {
          "code": "3600914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 141.461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 130187",
      "code_information": [
        {
          "code": "3600915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 59.4546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SHRT SCREW 6149.1042",
      "code_information": [
        {
          "code": "3600925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EZX 54MM BRXTB540",
      "code_information": [
        {
          "code": "3600938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5636,
          "minimum": 1183.56,
          "maximum": 4126.6792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2888.6754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-TOGA XL 0416-830-100",
      "code_information": [
        {
          "code": "3600948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 909,
          "minimum": 190.89,
          "maximum": 665.5698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 465.8989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20F 10MM 8279",
      "code_information": [
        {
          "code": "3600952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1894,
          "minimum": 397.74,
          "maximum": 1386.7868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 970.7508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS MALLEABLE 4MM",
      "code_information": [
        {
          "code": "3600954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1114.7745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG LIGHT MED C02051",
      "code_information": [
        {
          "code": "3600964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG SMALL C020500",
      "code_information": [
        {
          "code": "3600965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 228MM 56010228",
      "code_information": [
        {
          "code": "3600977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-JONES 3.2MM 56013200",
      "code_information": [
        {
          "code": "3600978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 976.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 5.5MM 56015500",
      "code_information": [
        {
          "code": "3600980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1584,
          "minimum": 332.64,
          "maximum": 1159.8048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 811.8634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CRYOTHERAPY FGS-7000",
      "code_information": [
        {
          "code": "3600997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5867,
          "minimum": 1232.07,
          "maximum": 4295.8174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3007.0722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXHAUST COLLECT FGS-7015",
      "code_information": [
        {
          "code": "3600999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONN-X 5.5/32-40 LNG 1119.0034",
      "code_information": [
        {
          "code": "3601000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1633.9775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-SUCT&ANTICOAG BT275",
      "code_information": [
        {
          "code": "3601009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ XF 4.2MM 0909-400-400",
      "code_information": [
        {
          "code": "3601031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 10MM 650.110",
      "code_information": [
        {
          "code": "3601032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-12\\\" THD AR-8967KT-12",
      "code_information": [
        {
          "code": "3601044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 192.715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS BIPOLAR 2MM",
      "code_information": [
        {
          "code": "3601053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1667,
          "minimum": 350.07,
          "maximum": 1220.5774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 854.4042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CRV 4MM P1-AU550",
      "code_information": [
        {
          "code": "3601055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4033.6898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-360-430 ALLOX2-FH13SE",
      "code_information": [
        {
          "code": "3601056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7446,
          "minimum": 1563.66,
          "maximum": 5451.9612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3816.3728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACENTESIS/PARACENTESI",
      "code_information": [
        {
          "code": "3601066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 701,
          "minimum": 147.21,
          "maximum": 513.2722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 359.2905,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G CMNT 0306-150-000",
      "code_information": [
        {
          "code": "3601086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 306.4989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CMNT 11G 0306-330-000",
      "code_information": [
        {
          "code": "3601087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 642,
          "minimum": 134.82,
          "maximum": 470.0724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 329.0507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TB AR-200",
      "code_information": [
        {
          "code": "3601096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 208.0912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRILL 3X320 P31-951-3032",
      "code_information": [
        {
          "code": "3601107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1963,
          "minimum": 412.23,
          "maximum": 1437.3086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1006.116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 7X200 P99-110-7019",
      "code_information": [
        {
          "code": "3601108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1434.5995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-110-4630",
      "code_information": [
        {
          "code": "3601109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1434.5995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.8X250 P99-100-3825",
      "code_information": [
        {
          "code": "3601110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1434.5995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-100-4630",
      "code_information": [
        {
          "code": "3601111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1434.5995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-HEAD 17.5 03.404.031S",
      "code_information": [
        {
          "code": "3601120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3893,
          "minimum": 817.53,
          "maximum": 2850.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1995.3182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CENTRAL VENOUS PED",
      "code_information": [
        {
          "code": "3601123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 669,
          "minimum": 140.49,
          "maximum": 489.8418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 342.8893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOD-PROTECTOR 69392",
      "code_information": [
        {
          "code": "3601124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 350,
          "minimum": 73.5,
          "maximum": 256.27,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 179.389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT ADULT DISP 731",
      "code_information": [
        {
          "code": "3601125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 273,
          "minimum": 57.33,
          "maximum": 199.8906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 139.9234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CHEST VENT HYFIN TWINPACK",
      "code_information": [
        {
          "code": "3601126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.6694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-VARISPEED 62-50201",
      "code_information": [
        {
          "code": "3601154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1913,
          "minimum": 401.73,
          "maximum": 1400.6986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 980.489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.5MM 72202189",
      "code_information": [
        {
          "code": "3601200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STR 14MM/SC 684.424",
      "code_information": [
        {
          "code": "3601216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SUCTION BALLARD 14FR",
      "code_information": [
        {
          "code": "3601234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 35FR 412351000",
      "code_information": [
        {
          "code": "3601235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 877.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 37FR 412371000",
      "code_information": [
        {
          "code": "3601236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 894.3823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 39FR 412391000",
      "code_information": [
        {
          "code": "3601237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 894.3823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-1.8X450 DIA PT 4933-8-010",
      "code_information": [
        {
          "code": "3601244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 682,
          "minimum": 143.22,
          "maximum": 499.3604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 349.5523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 120MM 4933-1-120",
      "code_information": [
        {
          "code": "3601245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 527,
          "minimum": 110.67,
          "maximum": 385.8694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 270.1086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 150MM 4933-1-150",
      "code_information": [
        {
          "code": "3601246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 527,
          "minimum": 110.67,
          "maximum": 385.8694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 270.1086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SCREW 6149.1040",
      "code_information": [
        {
          "code": "3601255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-IV SW 3000ML BAG S8505",
      "code_information": [
        {
          "code": "3601260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4MM CANN AR-8973-40S",
      "code_information": [
        {
          "code": "3601272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 800.5875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-PIN & PROT P45-610-1000",
      "code_information": [
        {
          "code": "3601289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 212.7041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-10MM P47-950-0001",
      "code_information": [
        {
          "code": "3601290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1933,
          "minimum": 405.93,
          "maximum": 1415.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 990.7398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-PROTECT P45-600-1000-S",
      "code_information": [
        {
          "code": "3601291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 106.6083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-AIR+MENISCAL CV 4722",
      "code_information": [
        {
          "code": "3601324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1307.4895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLUE STAPLE GCR40B",
      "code_information": [
        {
          "code": "3601345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1903,
          "minimum": 399.63,
          "maximum": 1393.3766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 975.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-GRAFT LG M00236320021",
      "code_information": [
        {
          "code": "3601349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 176,
          "minimum": 36.96,
          "maximum": 128.8672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 90.207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC SMALL 313-9013W",
      "code_information": [
        {
          "code": "3601350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 145.0488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC MED 313-9014W",
      "code_information": [
        {
          "code": "3601351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 145.0488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC LARGE 313-9015W",
      "code_information": [
        {
          "code": "3601352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 145.0488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-2.5 PRCSN MTCH HD 16CM",
      "code_information": [
        {
          "code": "3601354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1891,
          "minimum": 397.11,
          "maximum": 1384.5902,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 969.2131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROCH 1.1MM AR-18700-30",
      "code_information": [
        {
          "code": "3601375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.7369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STEP SOLID 1806-3026S",
      "code_information": [
        {
          "code": "3601387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1432,
          "minimum": 300.72,
          "maximum": 1048.5104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 733.9573,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47522",
      "code_information": [
        {
          "code": "3601390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47520",
      "code_information": [
        {
          "code": "3601391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-ENDOCLOT EA230",
      "code_information": [
        {
          "code": "3601393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 592,
          "minimum": 124.32,
          "maximum": 433.4624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.4237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 12\\\" 3.2MM",
      "code_information": [
        {
          "code": "3601397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 399,
          "minimum": 83.79,
          "maximum": 292.1478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 204.5035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.25MM  AR-18800-35",
      "code_information": [
        {
          "code": "3601403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 851,
          "minimum": 178.71,
          "maximum": 623.1022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 436.1715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-10X16X8/12° 1213.6088S",
      "code_information": [
        {
          "code": "3601406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6769,
          "minimum": 1421.49,
          "maximum": 4956.2618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3469.3833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 16X8MM 1128.2408",
      "code_information": [
        {
          "code": "3601407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2313.093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X14MM 184.014",
      "code_information": [
        {
          "code": "3601408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X16MM 184.016",
      "code_information": [
        {
          "code": "3601409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR SD 4.2X14MM 184.054",
      "code_information": [
        {
          "code": "3601410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI REFLUX",
      "code_information": [
        {
          "code": "3601418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-KANGAROO Y-PORT/PEG",
      "code_information": [
        {
          "code": "3601419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 18FR 8887605189",
      "code_information": [
        {
          "code": "3601420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 20FR 8887605205",
      "code_information": [
        {
          "code": "3601421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IN/OUTFLOW AR-6436",
      "code_information": [
        {
          "code": "3601433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1031,
          "minimum": 216.51,
          "maximum": 754.8982,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 528.4287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-3X7 AR-9300DS",
      "code_information": [
        {
          "code": "3601434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 423.8706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 314.6996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON PEG ENFIT",
      "code_information": [
        {
          "code": "3601438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.7164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G-TUBE ENFIT",
      "code_information": [
        {
          "code": "3601440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1234,
          "minimum": 259.14,
          "maximum": 903.5348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 632.4744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG ENFIT 24FR M00509061",
      "code_information": [
        {
          "code": "3601441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 361.8532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5020",
      "code_information": [
        {
          "code": "3601445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 846,
          "minimum": 177.66,
          "maximum": 619.4412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 433.6088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOCKWAVE STERILE CABLE",
      "code_information": [
        {
          "code": "3601446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16FR 20CM G01212",
      "code_information": [
        {
          "code": "3601447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-18FR 20CM G01328",
      "code_information": [
        {
          "code": "3601448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO JEJUNAL 8250-22",
      "code_information": [
        {
          "code": "3601452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1577,
          "minimum": 331.17,
          "maximum": 1154.6794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 808.2756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 8200-20",
      "code_information": [
        {
          "code": "3601453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 709.3554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10FR 50-7361",
      "code_information": [
        {
          "code": "3601454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 444,
          "minimum": 93.24,
          "maximum": 325.0968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 227.5678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 18140",
      "code_information": [
        {
          "code": "3601455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 502.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN 2.55MM MD 45303155",
      "code_information": [
        {
          "code": "3601456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DLP CORONARY 30315",
      "code_information": [
        {
          "code": "3601479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 510,
          "minimum": 107.1,
          "maximum": 373.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 261.3954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 875,
          "minimum": 183.75,
          "maximum": 640.675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 448.4725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 14FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.7164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.7164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC DRG MN12050",
      "code_information": [
        {
          "code": "3601484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1376.1699,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PREFORM-S3-4 39+6MM DWP2396",
      "code_information": [
        {
          "code": "3601576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4163.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 18X7MM 1128.1507",
      "code_information": [
        {
          "code": "3601577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2313.093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-20X55 8-17 5° 1122.1055",
      "code_information": [
        {
          "code": "3601578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 31589,
          "minimum": 6633.69,
          "maximum": 23129.4658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 16190.6261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 3X14 AR-8630-14",
      "code_information": [
        {
          "code": "3601580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1065.5707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 2.5X16 AR-8625-16",
      "code_information": [
        {
          "code": "3601581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1065.5707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LP/CRT 1.6X9 AR-18716-09",
      "code_information": [
        {
          "code": "3601582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1206,
          "minimum": 253.26,
          "maximum": 883.0332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 618.1232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CABLE PLATE 94-1200-08",
      "code_information": [
        {
          "code": "3601588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5867,
          "minimum": 1232.07,
          "maximum": 4295.8174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3007.0722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1195",
      "code_information": [
        {
          "code": "3601590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 492.5509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ1 CN P2ND1001",
      "code_information": [
        {
          "code": "3601591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 770.8602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-PEDI DSG P2HE2000",
      "code_information": [
        {
          "code": "3601592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8710,
          "minimum": 1829.1,
          "maximum": 6377.462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4464.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BALLARD/NEO BAA2103",
      "code_information": [
        {
          "code": "3601615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.9813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-DF 65MM/RT/STD 6495-2-040",
      "code_information": [
        {
          "code": "3601630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21681,
          "minimum": 4553.01,
          "maximum": 15874.8282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11112.3797,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CN/CC 7X45MM 8040-045",
      "code_information": [
        {
          "code": "3601631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1426.9114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-SMALL KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7523,
          "minimum": 1579.83,
          "maximum": 5508.3406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3855.8384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-LARGE KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7523,
          "minimum": 1579.83,
          "maximum": 5508.3406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3855.8384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 11X100MM 4922-8-100",
      "code_information": [
        {
          "code": "3601641",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1743,
          "minimum": 366.03,
          "maximum": 1276.2246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 893.3572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-WOUND CROWN",
      "code_information": [
        {
          "code": "3601647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 403.8815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN RAL 6MM B02236010",
      "code_information": [
        {
          "code": "3601652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1290.0632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN STD 6MM B02236001",
      "code_information": [
        {
          "code": "3601653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1290.0632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL LK 3.5 AR-8943-43",
      "code_information": [
        {
          "code": "3601667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1372.5821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ALEXIS M/L HR105",
      "code_information": [
        {
          "code": "3601692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 894.3823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5 SHORT 6149.1038S",
      "code_information": [
        {
          "code": "3601700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLEY-COUVEL 3-W",
      "code_information": [
        {
          "code": "3601705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.2495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-O3 OXIMETRY CEREBRAL",
      "code_information": [
        {
          "code": "3601707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM",
      "code_information": [
        {
          "code": "3601709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1393.0837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM BOX",
      "code_information": [
        {
          "code": "3601710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2537,
          "minimum": 532.77,
          "maximum": 1857.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1300.314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 23/M P01-900-2303",
      "code_information": [
        {
          "code": "3601722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1386.4207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ2 CN P2ND1002",
      "code_information": [
        {
          "code": "3601743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 770.8602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 16FR",
      "code_information": [
        {
          "code": "3601752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 502.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CV/XS 4MM P1-AU551",
      "code_information": [
        {
          "code": "3601759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4033.6898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 3/10F AR-98300OBT",
      "code_information": [
        {
          "code": "3601764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 423.8706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CIR/BEV P45-940-1001",
      "code_information": [
        {
          "code": "3601766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.0MM",
      "code_information": [
        {
          "code": "3601769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FLIPCUTTER III AR-1204FF",
      "code_information": [
        {
          "code": "3601777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2543,
          "minimum": 534.03,
          "maximum": 1861.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1303.3892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MGS 3MM AR-9628S",
      "code_information": [
        {
          "code": "3601781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1065.5707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-INFANT NEONATE CO2",
      "code_information": [
        {
          "code": "3601783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.0456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCAN 4MM AR-1204D",
      "code_information": [
        {
          "code": "3601799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1261,
          "minimum": 264.81,
          "maximum": 923.3042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 646.3129,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-.066CN 2.75MM AR-7000-14",
      "code_information": [
        {
          "code": "3601800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1264.4362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X6\\\" AR-8941-6",
      "code_information": [
        {
          "code": "3601803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X7\\\" AR-8941-7",
      "code_information": [
        {
          "code": "3601804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG ST TR AR-7823",
      "code_information": [
        {
          "code": "3601805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 851.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TROCH 1.35MM AR-8737-02",
      "code_information": [
        {
          "code": "3601814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.9376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JTIP 8164-2001-25",
      "code_information": [
        {
          "code": "3601822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.953,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRAY AR-200SP",
      "code_information": [
        {
          "code": "3601873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G MIS SHARP 501168",
      "code_information": [
        {
          "code": "3601880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE 6MM BH-220",
      "code_information": [
        {
          "code": "3601882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11846,
          "minimum": 2487.66,
          "maximum": 8673.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6071.5488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMAN.157X9\\\" KI71675",
      "code_information": [
        {
          "code": "3601893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 193,
          "minimum": 40.53,
          "maximum": 141.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 98.9202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .035X9\\\" DD KI71211",
      "code_information": [
        {
          "code": "3601894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FRACTURE KEX152EB",
      "code_information": [
        {
          "code": "3601895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 13504,
          "minimum": 2835.84,
          "maximum": 9887.6288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6921.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-TIB 11X360MM 1822-1136S",
      "code_information": [
        {
          "code": "3601898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5142,
          "minimum": 1079.82,
          "maximum": 3764.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2635.4807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LASER TRACH #5 102004050",
      "code_information": [
        {
          "code": "3601900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1245,
          "minimum": 261.45,
          "maximum": 911.589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 638.1123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-BLOOD COLLECT 04258",
      "code_information": [
        {
          "code": "3601933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 299.8359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77720",
      "code_information": [
        {
          "code": "3601934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 744,
          "minimum": 156.24,
          "maximum": 544.7568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 381.3298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .062X5\\\" 5050-249",
      "code_information": [
        {
          "code": "3601939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 143,
          "minimum": 30.03,
          "maximum": 104.7046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.2932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .045X5\\\" 5050-248",
      "code_information": [
        {
          "code": "3601940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 52.7916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLUTION-WOUND VASHE 16OZ 003",
      "code_information": [
        {
          "code": "3601945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX944",
      "code_information": [
        {
          "code": "3601947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 142.4861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM AO 702473",
      "code_information": [
        {
          "code": "3601950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2131,
          "minimum": 447.51,
          "maximum": 1560.3182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1092.2227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-7MM P20-910-7000",
      "code_information": [
        {
          "code": "3601961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 883.1064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXT-PERCUTANEOUS 9009",
      "code_information": [
        {
          "code": "3601976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 514.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 400MM BT 693.060S",
      "code_information": [
        {
          "code": "3601978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 269.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM 1032-115-000",
      "code_information": [
        {
          "code": "3601985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10370,
          "minimum": 2177.7,
          "maximum": 7592.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5315.0398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM 2PROBE 9700-020-200",
      "code_information": [
        {
          "code": "3601986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20104,
          "minimum": 4221.84,
          "maximum": 14720.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10304.1042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-AEOS STERILE PV012SU",
      "code_information": [
        {
          "code": "3601989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 462,
          "minimum": 97.02,
          "maximum": 338.2764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 236.7935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA 22FR 77422",
      "code_information": [
        {
          "code": "3601990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 286.5099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ENDO 5MM 174209",
      "code_information": [
        {
          "code": "3601996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1819,
          "minimum": 381.99,
          "maximum": 1331.8718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 932.3103,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 6213-119-070",
      "code_information": [
        {
          "code": "3601997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PURESOME TMD-07",
      "code_information": [
        {
          "code": "3601998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.8765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM AR-8943-36",
      "code_information": [
        {
          "code": "3602028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1198,
          "minimum": 251.58,
          "maximum": 877.1756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 614.0229,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PED LUMBAR 21G 645",
      "code_information": [
        {
          "code": "3602032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 112.2463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X C/D",
      "code_information": [
        {
          "code": "3602043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X C/D",
      "code_information": [
        {
          "code": "3602044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 147.6115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X C/D",
      "code_information": [
        {
          "code": "3602045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL C/D",
      "code_information": [
        {
          "code": "3602046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG C/D",
      "code_information": [
        {
          "code": "3602047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED C/D",
      "code_information": [
        {
          "code": "3602048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K SMALL C/D",
      "code_information": [
        {
          "code": "3602049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X A/B",
      "code_information": [
        {
          "code": "3602050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X A/B",
      "code_information": [
        {
          "code": "3602051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X A/B",
      "code_information": [
        {
          "code": "3602052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 147.6115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL A/B",
      "code_information": [
        {
          "code": "3602053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG A/B",
      "code_information": [
        {
          "code": "3602054",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 177.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED A/B",
      "code_information": [
        {
          "code": "3602055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.2495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN CMP 2.2 DSDS0022",
      "code_information": [
        {
          "code": "3602079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 976.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-JOINT PREP INST 9914PK01",
      "code_information": [
        {
          "code": "3602083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1203.9565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP 1.1 NT/SM 58820006",
      "code_information": [
        {
          "code": "3602084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 752,
          "minimum": 157.92,
          "maximum": 550.6144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 385.4301,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MICA 2X12MM 57SR0212",
      "code_information": [
        {
          "code": "3602085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2772,
          "minimum": 582.12,
          "maximum": 2029.6584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1420.7609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MICA INST BLADE 57S1MI07",
      "code_information": [
        {
          "code": "3602088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2242,
          "minimum": 470.82,
          "maximum": 1641.5924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1149.1147,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAMPATNCY FGS-0668",
      "code_information": [
        {
          "code": "3602103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRUDI SHAVER TSB4STR",
      "code_information": [
        {
          "code": "3602104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1633.9775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-BIENAIR AQUACARE 1600617",
      "code_information": [
        {
          "code": "3602106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-ORGO IRRIGATION 1502152",
      "code_information": [
        {
          "code": "3602107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 133.7729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-OSTOMY 18665",
      "code_information": [
        {
          "code": "3602109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-CLOSED TUBE 1320-0125S",
      "code_information": [
        {
          "code": "3602113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 491.5259,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 724G",
      "code_information": [
        {
          "code": "3602121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0 8756H",
      "code_information": [
        {
          "code": "3602122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.1788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0   8717H",
      "code_information": [
        {
          "code": "3602124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.1209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-EVARREST 2x4\\\" EVT5024",
      "code_information": [
        {
          "code": "3602126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4700,
          "minimum": 987,
          "maximum": 3441.34,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2408.938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-6 LEAD ECG SNAP BR-916PA",
      "code_information": [
        {
          "code": "3602128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1080,
          "minimum": 226.8,
          "maximum": 790.776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 553.5432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE",
      "code_information": [
        {
          "code": "3602129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 663.7393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TRI 4.0MM P1-AU411",
      "code_information": [
        {
          "code": "3602153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7067,
          "minimum": 1484.07,
          "maximum": 5174.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3622.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 894.3823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.4816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 702.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1065.5707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1426.9114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 587.3708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 C012D",
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        {
          "code": "3602196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 84.0566,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 851.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
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        {
          "code": "3602201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CY SCUL 3X12MM 58SC3012",
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        {
          "code": "3602216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2064.5111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
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        {
          "code": "3602226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
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        {
          "code": "3602229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 894.3823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
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        {
          "code": "3602230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
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        {
          "code": "3602233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.4816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
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        {
          "code": "3602234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 702.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
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        {
          "code": "3602235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1065.5707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
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        {
          "code": "3602236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1426.9114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 587.3708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3164,
          "minimum": 664.44,
          "maximum": 2316.6808,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1621.6766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 845.88,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2064.5111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
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        {
          "code": "3602265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 851.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
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        {
          "code": "3602266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-END +5 HUM 1830-0005S",
      "code_information": [
        {
          "code": "3602288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 236.88,
          "maximum": 825.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 578.1451,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
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        {
          "code": "3602290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
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        {
          "code": "3602293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 894.3823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
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        {
          "code": "3602294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 241.29,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
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        {
          "code": "3602297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 244.4816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
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        {
          "code": "3602298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 702.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
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        {
          "code": "3602308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 240.66,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT DL 15MM PROBE 9700-015-200",
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        {
          "code": "3602331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 22350,
          "minimum": 4693.5,
          "maximum": 16364.67,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 11455.269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2064.5111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3164,
          "minimum": 664.44,
          "maximum": 2316.6808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1621.6766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2185,
          "minimum": 458.85,
          "maximum": 1599.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1119.8999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2064.5111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 851.3289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 894.3823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.4816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 702.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1065.5707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1426.9114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 587.3708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT 125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5426,
          "minimum": 1139.46,
          "maximum": 3972.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2781.042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2185,
          "minimum": 458.85,
          "maximum": 1599.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1119.8999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5426,
          "minimum": 1139.46,
          "maximum": 3972.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2781.042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 13MM 7786713",
      "code_information": [
        {
          "code": "3602404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 7786703",
      "code_information": [
        {
          "code": "3602405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-MDI SPACER M 1082715",
      "code_information": [
        {
          "code": "3602410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 53.8167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRXPERION XP65/115VS",
      "code_information": [
        {
          "code": "3602411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 125.5723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH SZ5/90MM A0A14",
      "code_information": [
        {
          "code": "3602422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON LINEAR 40",
      "code_information": [
        {
          "code": "3602462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5202,
          "minimum": 1092.42,
          "maximum": 3808.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2666.2331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 111331",
      "code_information": [
        {
          "code": "3602483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 495.1136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SKIN CLOSURE CLR602US",
      "code_information": [
        {
          "code": "3602486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1556,
          "minimum": 326.76,
          "maximum": 1139.3032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 797.5122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-RADIAN FACET K 5526061",
      "code_information": [
        {
          "code": "3602487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1514,
          "minimum": 317.94,
          "maximum": 1108.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 775.9856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 11MM 7786711",
      "code_information": [
        {
          "code": "3602491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PELVIC STAB T-PODR",
      "code_information": [
        {
          "code": "3602497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 479.2249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIR-G BL-NOSE 3X900 0101-900S",
      "code_information": [
        {
          "code": "3602503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 642.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165MM S0210-200",
      "code_information": [
        {
          "code": "3602508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1940,
          "minimum": 407.4,
          "maximum": 1420.468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 994.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OPEN REAMER 03.168.004",
      "code_information": [
        {
          "code": "3602515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8067,
          "minimum": 1694.07,
          "maximum": 5906.6574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4134.6602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3X413MM 03.168.011",
      "code_information": [
        {
          "code": "3602516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3163,
          "minimum": 664.23,
          "maximum": 2315.9486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1621.164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LOWER 8/+0 END 2330-0000S",
      "code_information": [
        {
          "code": "3602538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1299,
          "minimum": 272.79,
          "maximum": 951.1278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 665.7895,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEART LOOP AV 9S44R",
      "code_information": [
        {
          "code": "3602540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 269.0835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-LOW PROFILE 6143.2527",
      "code_information": [
        {
          "code": "3602541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6702,
          "minimum": 1407.42,
          "maximum": 4907.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3435.0431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 160MM P45-180-0160",
      "code_information": [
        {
          "code": "3602542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4045,
          "minimum": 849.45,
          "maximum": 2961.749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2073.2243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 160MM P45-112-0140",
      "code_information": [
        {
          "code": "3602543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3462.7202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-G BALL 3X550 P31-955-1550",
      "code_information": [
        {
          "code": "3602544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1963,
          "minimum": 412.23,
          "maximum": 1437.3086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1006.116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-300MM THRED P45-310-0300",
      "code_information": [
        {
          "code": "3602545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRUTS-QA MOD MD P45-224-0170",
      "code_information": [
        {
          "code": "3602546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6214,
          "minimum": 1304.94,
          "maximum": 4549.8908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3184.9236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INST ARAGONITE MINI-DS",
      "code_information": [
        {
          "code": "3602550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1032.2556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOINT-BALL MOD P45-233-1000",
      "code_information": [
        {
          "code": "3602557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE 1.8 P99-202-1810",
      "code_information": [
        {
          "code": "3602569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 545.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCPP41D",
      "code_information": [
        {
          "code": "3602572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 92.7697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PRONE LAT STAB 6246.0200",
      "code_information": [
        {
          "code": "3602576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7446,
          "minimum": 1563.66,
          "maximum": 5451.9612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3816.3728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TT 2.4X9.25 AR-8870K",
      "code_information": [
        {
          "code": "3602593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 235,
          "minimum": 49.35,
          "maximum": 172.067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 120.4469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT W/CAP",
      "code_information": [
        {
          "code": "3602596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT WAVE+ 3.9M",
      "code_information": [
        {
          "code": "3602598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2457.6293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT FLEX 2.9MM",
      "code_information": [
        {
          "code": "3602599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2313.093,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT SMOL 2.9MM",
      "code_information": [
        {
          "code": "3602600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3012,
          "minimum": 632.52,
          "maximum": 2205.3864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1543.7705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3602604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4897,
          "minimum": 1028.37,
          "maximum": 3585.5834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2509.9084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3602606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4897,
          "minimum": 1028.37,
          "maximum": 3585.5834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2509.9084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.2L CN AR-8973-32LS",
      "code_information": [
        {
          "code": "3602614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 800.5875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°RT AR-4068-90R",
      "code_information": [
        {
          "code": "3602617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 749.3335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°LT AR-4068-90L",
      "code_information": [
        {
          "code": "3602618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 786.7489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°LT AR-4068-45L",
      "code_information": [
        {
          "code": "3602619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 786.7489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°RT AR-4068-45R",
      "code_information": [
        {
          "code": "3602620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 786.7489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPLEDAM AR-6530TD",
      "code_information": [
        {
          "code": "3602621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 205.5285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DTRAX SPINAL DX-22-300",
      "code_information": [
        {
          "code": "3602622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2602.1656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS 11G/5\\\"\\\" 0306-116-000",
      "code_information": [
        {
          "code": "3602624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 774,
          "minimum": 162.54,
          "maximum": 566.7228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 396.706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-OPTIFIX ABSORB 0113126",
      "code_information": [
        {
          "code": "3602652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HAWKINS 18GX15CM G05045",
      "code_information": [
        {
          "code": "3602657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 14FR G00996",
      "code_information": [
        {
          "code": "3602678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.3183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 12FR G00995",
      "code_information": [
        {
          "code": "3602679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-MWCE-18S-4/2-TORNADO",
      "code_information": [
        {
          "code": "3602685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1086,
          "minimum": 228.06,
          "maximum": 795.1692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 556.6184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-10-8 MREYE",
      "code_information": [
        {
          "code": "3602686",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 468.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-8 MREYE G42423",
      "code_information": [
        {
          "code": "3602687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 468.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION MREYE G42414",
      "code_information": [
        {
          "code": "3602690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 468.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-5 MREYE G42410",
      "code_information": [
        {
          "code": "3602691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 468.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-4 MREYE G42409",
      "code_information": [
        {
          "code": "3602692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 468.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-3 MREYE G42408",
      "code_information": [
        {
          "code": "3602693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 468.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-2-3 MREYE G42406",
      "code_information": [
        {
          "code": "3602694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 468.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 15MM X 15G",
      "code_information": [
        {
          "code": "3602699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1426,
          "minimum": 299.46,
          "maximum": 1044.1172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 730.882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 25MM X 15G",
      "code_information": [
        {
          "code": "3602700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1426,
          "minimum": 299.46,
          "maximum": 1044.1172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 730.882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CO 2.10MM NS1806.002 STE",
      "code_information": [
        {
          "code": "3602710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1658,
          "minimum": 348.18,
          "maximum": 1213.9876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 849.7913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2883-01-024",
      "code_information": [
        {
          "code": "3602763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1645,
          "minimum": 345.45,
          "maximum": 1204.469,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 843.1283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC SAW 1.27MM 71440375",
      "code_information": [
        {
          "code": "3602770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 379.2796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X340MM 1806-4260S",
      "code_information": [
        {
          "code": "3602772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1134,
          "minimum": 238.14,
          "maximum": 830.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 581.2204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 13X300MM 351.27",
      "code_information": [
        {
          "code": "3602773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3542,
          "minimum": 743.82,
          "maximum": 2593.4524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1815.4167,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 360.05S",
      "code_information": [
        {
          "code": "3602774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4064,
          "minimum": 853.44,
          "maximum": 2975.6608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2082.9626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 38FR 68138",
      "code_information": [
        {
          "code": "3602784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 462,
          "minimum": 97.02,
          "maximum": 338.2764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 236.7935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/15CM CA1815",
      "code_information": [
        {
          "code": "3602790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 30FR 68130",
      "code_information": [
        {
          "code": "3602796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 295.223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 32FR 68132",
      "code_information": [
        {
          "code": "3602797",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 602,
          "minimum": 126.42,
          "maximum": 440.7844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 308.5491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 36FR 68136",
      "code_information": [
        {
          "code": "3602798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 295.223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 34FR 68134",
      "code_information": [
        {
          "code": "3602799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR",
      "code_information": [
        {
          "code": "3602805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 436,
          "minimum": 91.56,
          "maximum": 319.2392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 223.4674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94895",
      "code_information": [
        {
          "code": "3602818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 533.5541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94835",
      "code_information": [
        {
          "code": "3602819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 533.5541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-2.1 FISSURE 5820-066-221",
      "code_information": [
        {
          "code": "3602851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 654.5136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 16G/15CM CA1615",
      "code_information": [
        {
          "code": "3602858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 14G/11CM CA1411",
      "code_information": [
        {
          "code": "3602859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 262.933,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 X523H",
      "code_information": [
        {
          "code": "3602867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0  X513H",
      "code_information": [
        {
          "code": "3602868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 34.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7 W/QC STD TP 71933035",
      "code_information": [
        {
          "code": "3602893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1169.6163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X250 AO 1806-8018S",
      "code_information": [
        {
          "code": "3602902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 589.421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-W/ NEEDLES #0 SUTURE",
      "code_information": [
        {
          "code": "3602933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-EXTREMITIES UNIVERSAL",
      "code_information": [
        {
          "code": "3602935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1194",
      "code_information": [
        {
          "code": "3602936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 492.5509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ201",
      "code_information": [
        {
          "code": "3602938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1734.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ101",
      "code_information": [
        {
          "code": "3602939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1734.9479,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 180MM P45-112-0180",
      "code_information": [
        {
          "code": "3602943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3462.7202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 180MM P45-180-0180",
      "code_information": [
        {
          "code": "3602944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4045,
          "minimum": 849.45,
          "maximum": 2961.749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2073.2243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-4H THRED P45-921-0004",
      "code_information": [
        {
          "code": "3602945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2618,
          "minimum": 549.78,
          "maximum": 1916.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1341.8297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CALIBRA 4X165MM 0225-000",
      "code_information": [
        {
          "code": "3602953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2376,
          "minimum": 498.96,
          "maximum": 1739.7072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1217.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5MMPINX9.5MMROD 1151-200",
      "code_information": [
        {
          "code": "3602954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3458,
          "minimum": 726.18,
          "maximum": 2531.9476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1772.3633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-9.5 X 9.5MM ROD 1151-200",
      "code_information": [
        {
          "code": "3602955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3458,
          "minimum": 726.18,
          "maximum": 2531.9476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1772.3633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X150MM 1152-150",
      "code_information": [
        {
          "code": "3602956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X200MM 1152-200",
      "code_information": [
        {
          "code": "3602957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X250MM 1152-250",
      "code_information": [
        {
          "code": "3602958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X300 1152-300",
      "code_information": [
        {
          "code": "3602959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN ASSEM 1158-000",
      "code_information": [
        {
          "code": "3602960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6458,
          "minimum": 1356.18,
          "maximum": 4728.5476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3309.9833,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VENASEAL CLOSURE VS-404",
      "code_information": [
        {
          "code": "3602966",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2529.8974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-5.5 P20-910-5500",
      "code_information": [
        {
          "code": "3602974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 883.1064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK -.5 P20-915-5500",
      "code_information": [
        {
          "code": "3602976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 883.1064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PROTECT 5.0 P45-198-5000",
      "code_information": [
        {
          "code": "3602978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5320",
      "code_information": [
        {
          "code": "3603015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1167,
          "minimum": 245.07,
          "maximum": 854.4774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 598.1342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-150MM THRED P45-310-0150",
      "code_information": [
        {
          "code": "3603022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 349.0397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-CUBE 4H P45-925-0004",
      "code_information": [
        {
          "code": "3603023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2738,
          "minimum": 574.98,
          "maximum": 2004.7636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1403.3345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-3/16\\\" SQ P99-000-316P",
      "code_information": [
        {
          "code": "3603028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 8MM P45-914-0003",
      "code_information": [
        {
          "code": "3603029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCRW-POST+NUT SET B0223000",
      "code_information": [
        {
          "code": "3603037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1290.0632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.35MM AR-5050-01",
      "code_information": [
        {
          "code": "3603040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ULTRALOOP-HS FIBER 72205445",
      "code_information": [
        {
          "code": "3603051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 441.8095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM PROBE 9700-020-100",
      "code_information": [
        {
          "code": "3603057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21773,
          "minimum": 4572.33,
          "maximum": 15942.1906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 11159.5334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/F P01-900-1702",
      "code_information": [
        {
          "code": "3603060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1386.4207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F40 64611",
      "code_information": [
        {
          "code": "3603068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63306",
      "code_information": [
        {
          "code": "3603069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.4328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63305",
      "code_information": [
        {
          "code": "3603070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.4328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE SMALL",
      "code_information": [
        {
          "code": "3603071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.3607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE LARGE",
      "code_information": [
        {
          "code": "3603072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.3607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE MEDIUM",
      "code_information": [
        {
          "code": "3603073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.3607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYNG SZ4 321400000U",
      "code_information": [
        {
          "code": "3603074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL WIDE",
      "code_information": [
        {
          "code": "3603075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.7369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL FITPACK",
      "code_information": [
        {
          "code": "3603076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 99.4328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOWS-SOLO FITPACK SLP1SMSLA",
      "code_information": [
        {
          "code": "3603077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X400MM 1152-400",
      "code_information": [
        {
          "code": "3603081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1183.4549,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP427H",
      "code_information": [
        {
          "code": "3603082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOULTION-WOUND VASHE 118ML",
      "code_information": [
        {
          "code": "3603095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 225,
          "minimum": 47.25,
          "maximum": 164.745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 115.3215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ULTRABRAID SZ2 7210915",
      "code_information": [
        {
          "code": "3603096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.9877,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-50 COBLATION 72290037",
      "code_information": [
        {
          "code": "3603101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1887,
          "minimum": 396.27,
          "maximum": 1381.6614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 967.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3603102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 517,
          "minimum": 108.57,
          "maximum": 378.5474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 264.9832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-5.5 72202530",
      "code_information": [
        {
          "code": "3603103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 562.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-HRVST SYS SK27",
      "code_information": [
        {
          "code": "3603104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2876.887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INST-GUIDE RELEASE SN20",
      "code_information": [
        {
          "code": "3603105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-HK BONE REMOVAL SN25",
      "code_information": [
        {
          "code": "3603107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRIPLE EDGE INST SN21",
      "code_information": [
        {
          "code": "3603108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0 C013D",
      "code_information": [
        {
          "code": "3603114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-FILSHIE AVM-851J",
      "code_information": [
        {
          "code": "3603115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1434,
          "minimum": 301.14,
          "maximum": 1049.9748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 734.9824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERC SUTURE AR-7267",
      "code_information": [
        {
          "code": "3603119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 14MM 2022-30-014S",
      "code_information": [
        {
          "code": "3603135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 819.0389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 16MM 2022-30-016S",
      "code_information": [
        {
          "code": "3603136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 819.0389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PIN PROT WHT 5027-1-040",
      "code_information": [
        {
          "code": "3603139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREADED CTF03",
      "code_information": [
        {
          "code": "3603177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3603179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2457.6293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3603180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2457.6293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 8F",
      "code_information": [
        {
          "code": "3603181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2457.6293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 9F",
      "code_information": [
        {
          "code": "3603182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2457.6293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 8MM 022108-10",
      "code_information": [
        {
          "code": "3603183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TPR 3MM 5407-FA3-030",
      "code_information": [
        {
          "code": "3603184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1282,
          "minimum": 269.22,
          "maximum": 938.6804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 657.0763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 6MM 5820-010-160",
      "code_information": [
        {
          "code": "3603185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 765.7348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RASP-HELI 3.2MM 5120-080-030",
      "code_information": [
        {
          "code": "3603186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1446,
          "minimum": 303.66,
          "maximum": 1058.7612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 741.1328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 7205306",
      "code_information": [
        {
          "code": "3603188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 233.2057,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 1683H",
      "code_information": [
        {
          "code": "3603192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 37.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3603196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3050,
          "minimum": 640.5,
          "maximum": 2233.21,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1563.247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT C0R47",
      "code_information": [
        {
          "code": "3603197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS CFF74",
      "code_information": [
        {
          "code": "3603198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEEDLE WINGED INF WNIS01",
      "code_information": [
        {
          "code": "3603199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 55.3543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED CTF73",
      "code_information": [
        {
          "code": "3603214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANN-VENOUS HI FLO 24FR 69324",
      "code_information": [
        {
          "code": "3603215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 211.679,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A404",
      "code_information": [
        {
          "code": "3603218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 201.4282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR 72201513",
      "code_information": [
        {
          "code": "3603219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 656,
          "minimum": 137.76,
          "maximum": 480.3232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.2262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3603221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 615,
          "minimum": 129.15,
          "maximum": 450.303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 315.2121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOVIE-E-Z CLEAN 0014A",
      "code_information": [
        {
          "code": "3603224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.4405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SOMFIT 7037-1001-00",
      "code_information": [
        {
          "code": "3603227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MOD 12MM 2022-30-012S",
      "code_information": [
        {
          "code": "3603247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 819.0389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3603277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-ZINC OXIDE REMDEY 4OZ",
      "code_information": [
        {
          "code": "3603279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.4405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT X 2.4/45° 378824",
      "code_information": [
        {
          "code": "3603290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 308,
          "minimum": 64.68,
          "maximum": 225.5176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 157.8623,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-STR SP 15° 378235",
      "code_information": [
        {
          "code": "3603291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.2823,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM BP 0808-115-800",
      "code_information": [
        {
          "code": "3603299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10281,
          "minimum": 2159.01,
          "maximum": 7527.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5269.4237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-11G VP 0605-411-000",
      "code_information": [
        {
          "code": "3603300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2421,
          "minimum": 508.41,
          "maximum": 1772.6562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1240.8593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-10G VP 0605-410-000",
      "code_information": [
        {
          "code": "3603301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2421,
          "minimum": 508.41,
          "maximum": 1772.6562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1240.8593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BL 3X600 AR-9091BK-30S",
      "code_information": [
        {
          "code": "3603303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL 4.2MM AR-9091-42",
      "code_information": [
        {
          "code": "3603304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1462.2766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CM VP 11G 0306-511-000",
      "code_information": [
        {
          "code": "3603319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 604,
          "minimum": 126.84,
          "maximum": 442.2488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 309.5742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5 REAMING 6143.2571",
      "code_information": [
        {
          "code": "3603340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM F/ANCHOR 72203785",
      "code_information": [
        {
          "code": "3603349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1506,
          "minimum": 316.26,
          "maximum": 1102.6932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 771.8852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X5MM 60-16005",
      "code_information": [
        {
          "code": "3603351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 658.1014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X26MM 60-16526",
      "code_information": [
        {
          "code": "3603355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1442,
          "minimum": 302.82,
          "maximum": 1055.8324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 739.0827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X35 92-16135",
      "code_information": [
        {
          "code": "3603356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1863,
          "minimum": 391.23,
          "maximum": 1364.0886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 954.862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X50/5M 60-15105",
      "code_information": [
        {
          "code": "3603363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1488,
          "minimum": 312.48,
          "maximum": 1089.5136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 762.6595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X110/20M 60-15620",
      "code_information": [
        {
          "code": "3603364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1393.0837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 VICRYL PLUS VCP762D",
      "code_information": [
        {
          "code": "3603378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 109.6836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13X50/13G NN-2003",
      "code_information": [
        {
          "code": "3603396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10986.2949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL DIST 2.8MM 4040-000",
      "code_information": [
        {
          "code": "3603404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1975,
          "minimum": 414.75,
          "maximum": 1446.095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1012.2665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 1.5X230MM 0109-230",
      "code_information": [
        {
          "code": "3603406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 587.3708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE HAND 415S002350",
      "code_information": [
        {
          "code": "3603407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1272.6368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CIRCUIT NEONATE DUAL LIMB",
      "code_information": [
        {
          "code": "3603429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 754,
          "minimum": 158.34,
          "maximum": 552.0788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 386.4552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SUCTION TABLE 8Q70R",
      "code_information": [
        {
          "code": "3603430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 633,
          "minimum": 132.93,
          "maximum": 463.4826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 324.4378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5X150 CN P41-910-5015",
      "code_information": [
        {
          "code": "3603431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 838.5154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGATION P65-001-0006-SK",
      "code_information": [
        {
          "code": "3603437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1316,
          "minimum": 276.36,
          "maximum": 963.5752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 674.5026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-QUAD TIP 2762-01-0003",
      "code_information": [
        {
          "code": "3603444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1617.0637,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2.5CM M00510880",
      "code_information": [
        {
          "code": "3603498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 877.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2CM M00510870",
      "code_information": [
        {
          "code": "3603499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 877.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GENERATOR-RF PROC RLVRFGPR",
      "code_information": [
        {
          "code": "3603504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 946.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ADD ACCESS INST RLV0075",
      "code_information": [
        {
          "code": "3603508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2024.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ACCESS INSTRUMENT RLV0045",
      "code_information": [
        {
          "code": "3603510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9838,
          "minimum": 2065.98,
          "maximum": 7203.3836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5042.3685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DAVINCI INSUFF TUBE 470551",
      "code_information": [
        {
          "code": "3603512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1264,
          "minimum": 265.44,
          "maximum": 925.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 647.8506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/10CM NN-8006",
      "code_information": [
        {
          "code": "3603527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 16702,
          "minimum": 3507.42,
          "maximum": 12229.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 8560.4431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X60/13G NN-2004",
      "code_information": [
        {
          "code": "3603530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10986.2949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 40X11 SM-4011M",
      "code_information": [
        {
          "code": "3603538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ALLOGRAFT-22.5MM ABS-4057D-225",
      "code_information": [
        {
          "code": "3603542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5686,
          "minimum": 1194.06,
          "maximum": 4163.2892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2914.3024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL-1.5x48MM 03.130.212",
      "code_information": [
        {
          "code": "3603544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 530.4789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP76",
      "code_information": [
        {
          "code": "3603545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE 9X102 HTOE 05-306",
      "code_information": [
        {
          "code": "3603547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 201.9408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.35X150 AR-8943-01S",
      "code_information": [
        {
          "code": "3603548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.7369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLECTOR-SPECIMEN NN-9002",
      "code_information": [
        {
          "code": "3603569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/13CM NN-8007",
      "code_information": [
        {
          "code": "3603587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 18660,
          "minimum": 3918.6,
          "maximum": 13662.852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 9563.9964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X95/13G NN-2006",
      "code_information": [
        {
          "code": "3603588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10986.2949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X75/13G NN-2005",
      "code_information": [
        {
          "code": "3603589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 10986.2949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-MYRID NICO NN-9001",
      "code_information": [
        {
          "code": "3603590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 57.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 7FRX65C",
      "code_information": [
        {
          "code": "3603592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1624,
          "minimum": 341.04,
          "maximum": 1189.0928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 832.365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 5FRX50C",
      "code_information": [
        {
          "code": "3603593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1624,
          "minimum": 341.04,
          "maximum": 1189.0928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 832.365,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 9FRX65C",
      "code_information": [
        {
          "code": "3603594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1882,
          "minimum": 395.22,
          "maximum": 1378.0004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 964.6003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-20-22FR/45CM G52835",
      "code_information": [
        {
          "code": "3603768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1759,
          "minimum": 369.39,
          "maximum": 1287.9398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 901.5579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16-18FR/45CM G52834",
      "code_information": [
        {
          "code": "3603769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1759,
          "minimum": 369.39,
          "maximum": 1287.9398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 901.5579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-32-35MM 102024003",
      "code_information": [
        {
          "code": "3603771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.4X27 ST 60-14126",
      "code_information": [
        {
          "code": "3603794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 569.9445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOWN-WARMING BEAR PAW 81001",
      "code_information": [
        {
          "code": "3603809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 88.6694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPYSCOPE DS II M00546610",
      "code_information": [
        {
          "code": "3603810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12212,
          "minimum": 2564.52,
          "maximum": 8941.6264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6259.1385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-EHL 1.9F 375CM M00546620",
      "code_information": [
        {
          "code": "3603814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2879,
          "minimum": 604.59,
          "maximum": 2108.0038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1475.6027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONEMILL MD 5420-MED-000",
      "code_information": [
        {
          "code": "3603815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3354,
          "minimum": 704.34,
          "maximum": 2455.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1719.0592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CRV DIAMOND 15° 1600650",
      "code_information": [
        {
          "code": "3603818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CYLINDER 60° 1600578",
      "code_information": [
        {
          "code": "3603819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.9X27MM 60-19126",
      "code_information": [
        {
          "code": "3603820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 569.9445,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X200MM P99-192-1620",
      "code_information": [
        {
          "code": "3603836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 514.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2.0 3846T",
      "code_information": [
        {
          "code": "3603837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6.1505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y415H",
      "code_information": [
        {
          "code": "3603838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6.1505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 7-0 Z135H",
      "code_information": [
        {
          "code": "3603876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 273,
          "minimum": 57.33,
          "maximum": 199.8906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 139.9234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 45X6 SM-4506",
      "code_information": [
        {
          "code": "3603888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-38MM ARS743201",
      "code_information": [
        {
          "code": "3603895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 805.2003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-14X127MM ARS743303",
      "code_information": [
        {
          "code": "3603897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 805.2003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE .9MM 57S90005",
      "code_information": [
        {
          "code": "3603901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 330.5883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE 1.4MM 57S90004",
      "code_information": [
        {
          "code": "3603902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 330.5883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM MXM-072-19",
      "code_information": [
        {
          "code": "3603904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 922.0595,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-76/3 ARS743202",
      "code_information": [
        {
          "code": "3603910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 805.2003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 8.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603923",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 6.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SM CHLD NR34015813",
      "code_information": [
        {
          "code": "3603926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.6161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015814",
      "code_information": [
        {
          "code": "3603927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.6161,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PRO-FLOW NR37000145",
      "code_information": [
        {
          "code": "3603928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SPO2 ADULT NR37004030",
      "code_information": [
        {
          "code": "3603929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 41.5157,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMETRY EM951160CP",
      "code_information": [
        {
          "code": "3603931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.5582,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ADULT NR34015818",
      "code_information": [
        {
          "code": "3603932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.4405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASALNR354S5011",
      "code_information": [
        {
          "code": "3603933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.2399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015816",
      "code_information": [
        {
          "code": "3603934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG WEBB NR104B1420",
      "code_information": [
        {
          "code": "3603935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.1427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-EEG 8OZ NR10200005",
      "code_information": [
        {
          "code": "3603936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 529,
          "minimum": 111.09,
          "maximum": 387.3338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 271.1337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUPREP-4OZ TUBE NR10210004",
      "code_information": [
        {
          "code": "3603937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 80.9813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THERMOCAN NR34015808",
      "code_information": [
        {
          "code": "3603938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 30.2399,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR/6.7MM 80220",
      "code_information": [
        {
          "code": "3603955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.353,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CLEARVUE LARYNG #3",
      "code_information": [
        {
          "code": "3603957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 104.0456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NOMOLINE LH NASAL/ORAL",
      "code_information": [
        {
          "code": "3603958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 106.6083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 22FR BE2050",
      "code_information": [
        {
          "code": "3603960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.4351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 18FR BE6050",
      "code_information": [
        {
          "code": "3603961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 610.4351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LITHOTRIPER PROBE 3.9MM",
      "code_information": [
        {
          "code": "3603972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4400,
          "minimum": 924,
          "maximum": 3221.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2255.176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T-15 TORQUE 702750",
      "code_information": [
        {
          "code": "3603979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3611,
          "minimum": 758.31,
          "maximum": 2643.9742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1850.7819,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIMITER-TORQUE 2.5NM 702760",
      "code_information": [
        {
          "code": "3603985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4015,
          "minimum": 843.15,
          "maximum": 2939.783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2057.8481,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/15 STPL THN00482",
      "code_information": [
        {
          "code": "3603988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2099,
          "minimum": 440.79,
          "maximum": 1536.8878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1075.8215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/20 STPL THN00483",
      "code_information": [
        {
          "code": "3603989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2099,
          "minimum": 440.79,
          "maximum": 1536.8878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1075.8215,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA 22.5FR 7275",
      "code_information": [
        {
          "code": "3604022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM*CLEARIFY 21-345",
      "code_information": [
        {
          "code": "3604025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 CHROMIC GUT 792G",
      "code_information": [
        {
          "code": "3604027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-NANO 29.5X7MM SM-3115",
      "code_information": [
        {
          "code": "3604043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-MET 20MM MPN20120",
      "code_information": [
        {
          "code": "3604048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHAL 20MM MPN20020",
      "code_information": [
        {
          "code": "3604049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM SHT MSTD1030",
      "code_information": [
        {
          "code": "3604050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CIRCUMCISION 1.45CM",
      "code_information": [
        {
          "code": "3604060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 605,
          "minimum": 127.05,
          "maximum": 442.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 310.0867,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE DUAL 844023S",
      "code_information": [
        {
          "code": "3604137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 291,
          "minimum": 61.11,
          "maximum": 213.0702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 149.1491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE SINGLE 800099S",
      "code_information": [
        {
          "code": "3604138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 2X200 MSG20200",
      "code_information": [
        {
          "code": "3604156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 366.9786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.6 F/5.5MM MSN10013",
      "code_information": [
        {
          "code": "3604157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1393.0837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM LNG MSTD0030",
      "code_information": [
        {
          "code": "3604158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 615.5605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA-G GENERATION 2",
      "code_information": [
        {
          "code": "3604162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10740,
          "minimum": 2255.4,
          "maximum": 7863.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5504.6796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-STAPLE SZ THN00292",
      "code_information": [
        {
          "code": "3604165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1032.2556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 5.0MM 3100-01-0005",
      "code_information": [
        {
          "code": "3604167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.5968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 2.4MM 2900-04-0229",
      "code_information": [
        {
          "code": "3604168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1431,
          "minimum": 300.51,
          "maximum": 1047.7782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 733.4447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-6.5MM 3100-01-0007",
      "code_information": [
        {
          "code": "3604169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.5968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-7X90 3200-01-7090",
      "code_information": [
        {
          "code": "3604170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 15795,
          "minimum": 3316.95,
          "maximum": 11565.099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 8095.5693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SONATA DE-001-10",
      "code_information": [
        {
          "code": "3604172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 877,
          "minimum": 184.17,
          "maximum": 642.1394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 449.4976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS BONE BX 0306-115-000",
      "code_information": [
        {
          "code": "3604196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 798,
          "minimum": 167.58,
          "maximum": 584.2956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 409.0069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-DSG XS 2.5MM P1-AU514",
      "code_information": [
        {
          "code": "3604197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 4033.6898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DISTRACTOR 12MM 02.600.022",
      "code_information": [
        {
          "code": "3604198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 508.4397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-#0/8\\\"\\\" GREEN VLOCA008L",
      "code_information": [
        {
          "code": "3604209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1317,
          "minimum": 276.57,
          "maximum": 964.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 675.0152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VICRYL VCP104G",
      "code_information": [
        {
          "code": "3604215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX977",
      "code_information": [
        {
          "code": "3604217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MINITAPE-LOOPED 72205435",
      "code_information": [
        {
          "code": "3604218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 913,
          "minimum": 191.73,
          "maximum": 668.4986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 467.949,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATE STD 20MM M0056183",
      "code_information": [
        {
          "code": "3604224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 297,
          "minimum": 62.37,
          "maximum": 217.4634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.2244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ACESSA 7300",
      "code_information": [
        {
          "code": "3604227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14892,
          "minimum": 3127.32,
          "maximum": 10903.9224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7632.7457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-HEAD SILVERMAN SZ F",
      "code_information": [
        {
          "code": "3604228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X12MM AR-300-B003",
      "code_information": [
        {
          "code": "3604244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1264.4362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 3.1X20MM AR-300-B202",
      "code_information": [
        {
          "code": "3604247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1264.4362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUT 2 P41-960-0020",
      "code_information": [
        {
          "code": "3604263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 883.1064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5.5X150 CN P41-910-5515",
      "code_information": [
        {
          "code": "3604264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 838.5154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X150 CN P41-910-4015",
      "code_information": [
        {
          "code": "3604265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 838.5154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-GPS LONG 6143.2515",
      "code_information": [
        {
          "code": "3604278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6702,
          "minimum": 1407.42,
          "maximum": 4907.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3435.0431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 8.0",
      "code_information": [
        {
          "code": "3604284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 7.5",
      "code_information": [
        {
          "code": "3604285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED",
      "code_information": [
        {
          "code": "3604286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER TRACH PORTEX 100",
      "code_information": [
        {
          "code": "3604287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.7273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEMALE TO FEMALE",
      "code_information": [
        {
          "code": "3604289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-1.8MM PERK AR-3610PK-3",
      "code_information": [
        {
          "code": "3604294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1586,
          "minimum": 333.06,
          "maximum": 1161.2692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 812.8884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 6X7 AR-6535TD",
      "code_information": [
        {
          "code": "3604297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 205.5285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SR8 GEMINI AR-6572",
      "code_information": [
        {
          "code": "3604301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 205.5285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLSRE SKN 22CM EF70401",
      "code_information": [
        {
          "code": "3604305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 711,
          "minimum": 149.31,
          "maximum": 520.5942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 364.4159,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH 14 1/4\\\" 020116801",
      "code_information": [
        {
          "code": "3604307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 668.8647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-TISSUE HIGH EX71010",
      "code_information": [
        {
          "code": "3604311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7/F 2.4 AR-8916-18",
      "code_information": [
        {
          "code": "3604317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 275.234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-WIRE FIX XL 76-10104",
      "code_information": [
        {
          "code": "3604319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1375,
          "minimum": 288.75,
          "maximum": 1006.775,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 704.7425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR PEDIATRIC S-1003",
      "code_information": [
        {
          "code": "3604329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 264,
          "minimum": 55.44,
          "maximum": 193.3008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 135.3106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT SHORT 71-6130S",
      "code_information": [
        {
          "code": "3604330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10354,
          "minimum": 2174.34,
          "maximum": 7581.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5306.8392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 4H 76-10140",
      "code_information": [
        {
          "code": "3604333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 867.2177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 2H 76-10125",
      "code_information": [
        {
          "code": "3604334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 867.2177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 200MM 76-11200",
      "code_information": [
        {
          "code": "3604335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 589.9335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 115MM 76-11115",
      "code_information": [
        {
          "code": "3604337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 934,
          "minimum": 196.14,
          "maximum": 683.8748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 478.7124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FH 4.2MM AR-9091F-42",
      "code_information": [
        {
          "code": "3604351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1462.2766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CON 4.3X13MM AR-300-B101",
      "code_information": [
        {
          "code": "3604352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2470,
          "minimum": 518.7,
          "maximum": 1808.534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1265.9738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE SKIN EF70466",
      "code_information": [
        {
          "code": "3604355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 933,
          "minimum": 195.93,
          "maximum": 683.1426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 478.1998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEN-ADHESIVE EP70412",
      "code_information": [
        {
          "code": "3604356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 93.7948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACTIVALVE-PROVOX STRONG 7161",
      "code_information": [
        {
          "code": "3604357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2024.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET ACCESS INST LV3 RLV0055",
      "code_information": [
        {
          "code": "3604369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12997,
          "minimum": 2729.37,
          "maximum": 9516.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 6661.4824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.6X200 AR-5050K-1",
      "code_information": [
        {
          "code": "3604376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 244.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM C P01-901-0901-S",
      "code_information": [
        {
          "code": "3604385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1386.4207,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET SCREW T7 5560010000",
      "code_information": [
        {
          "code": "3604395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 452.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-FOGARTY DSOFT33",
      "code_information": [
        {
          "code": "3604398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 185.0269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-DRAIN/FLUSH LL AFA-LL",
      "code_information": [
        {
          "code": "3604403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 114.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #4",
      "code_information": [
        {
          "code": "3604406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 208.0912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #3",
      "code_information": [
        {
          "code": "3604407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 208.0912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-6 THD/10 HEX 76-10180",
      "code_information": [
        {
          "code": "3604415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 235,
          "minimum": 49.35,
          "maximum": 172.067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 120.4469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-FLANGE 10HX 76-10182",
      "code_information": [
        {
          "code": "3604416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 161.4501,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD +3OS/25MM MWJ007",
      "code_information": [
        {
          "code": "3604423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5858,
          "minimum": 1230.18,
          "maximum": 4289.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3002.4593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODEL-REV BONE MWJ015",
      "code_information": [
        {
          "code": "3604424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.0 A-3938",
      "code_information": [
        {
          "code": "3604432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2061,
          "minimum": 432.81,
          "maximum": 1509.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1056.3449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 16FR 26-016",
      "code_information": [
        {
          "code": "3604433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 466.4114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 12FR 26-012",
      "code_information": [
        {
          "code": "3604434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 466.4114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 18FR 26-018",
      "code_information": [
        {
          "code": "3604435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 466.4114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-NYLON 11MM/265ML CD005",
      "code_information": [
        {
          "code": "3604438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 336.7388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-6X150 CN P41-910-6015",
      "code_information": [
        {
          "code": "3604457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 838.5154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CAL 5.5MM S0288-200",
      "code_information": [
        {
          "code": "3604470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2470,
          "minimum": 518.7,
          "maximum": 1808.534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1265.9738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.6MM TRC AR-18700-71",
      "code_information": [
        {
          "code": "3604479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 153.2495,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO",
      "code_information": [
        {
          "code": "3604489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 686,
          "minimum": 144.06,
          "maximum": 502.2892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 351.6024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1069210",
      "code_information": [
        {
          "code": "3604490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.6051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-HO 7/1.6X80 P99-205-1608",
      "code_information": [
        {
          "code": "3604512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 545.8551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GRAFT SIZING AR-1676ST",
      "code_information": [
        {
          "code": "3604518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1065.5707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMANN .157X9\\\"\\\" KI71615",
      "code_information": [
        {
          "code": "3604550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 100.9704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL SP-78105",
      "code_information": [
        {
          "code": "3604567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 652.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 1MM 5820-013-010",
      "code_information": [
        {
          "code": "3604568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 654.5136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 12X18/2 DS24",
      "code_information": [
        {
          "code": "3604569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 769,
          "minimum": 161.49,
          "maximum": 563.0618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 394.1433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/0 DS26",
      "code_information": [
        {
          "code": "3604570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 832,
          "minimum": 174.72,
          "maximum": 609.1904,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 426.4333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/2 DS28",
      "code_information": [
        {
          "code": "3604571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 815,
          "minimum": 171.15,
          "maximum": 596.743,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 417.7201,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 29/37 TF2937O",
      "code_information": [
        {
          "code": "3604581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 312.6494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-AMPLATZ 8F M0062601010",
      "code_information": [
        {
          "code": "3604584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 481,
          "minimum": 101.01,
          "maximum": 352.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 246.5317,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-33MM LF EVERGRIP33",
      "code_information": [
        {
          "code": "3604594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 359,
          "minimum": 75.39,
          "maximum": 262.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEM 19F/6.3 96570-119",
      "code_information": [
        {
          "code": "3604596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2245,
          "minimum": 471.45,
          "maximum": 1643.789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1150.6523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 19F/6.3MM 96530-119",
      "code_information": [
        {
          "code": "3604597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1272.6368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 21F/7MM 96530-121",
      "code_information": [
        {
          "code": "3604598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1272.6368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WHITE 15X12MM DLP-W11",
      "code_information": [
        {
          "code": "3604599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-YELLOW 15X12MM DLP-S11",
      "code_information": [
        {
          "code": "3604600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-11MM 261222",
      "code_information": [
        {
          "code": "3604605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1372.5821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 650-750CC SZHP68650",
      "code_information": [
        {
          "code": "3604611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 550-640CC SZHP68550",
      "code_information": [
        {
          "code": "3604612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 425-455CC SZHP68425",
      "code_information": [
        {
          "code": "3604613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.3922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 320-340CC SZHP68320",
      "code_information": [
        {
          "code": "3604614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 281.3845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 200-260CC SZHP68200",
      "code_information": [
        {
          "code": "3604615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 750-800CC SZHP68750",
      "code_information": [
        {
          "code": "3604616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 407.9818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 2MM 5820-010-120",
      "code_information": [
        {
          "code": "3604621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 3MM 5820-010-130",
      "code_information": [
        {
          "code": "3604622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 4MM 5820-010-140",
      "code_information": [
        {
          "code": "3604623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 3MM 5820-012-030",
      "code_information": [
        {
          "code": "3604624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 654.5136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 4MM 5820-012-040",
      "code_information": [
        {
          "code": "3604625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 765.7348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 3 5820-013-030",
      "code_information": [
        {
          "code": "3604626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 4 5820-013-040",
      "code_information": [
        {
          "code": "3604627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 699.6171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SAHARA S-1150-08LF",
      "code_information": [
        {
          "code": "3604628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1182,
          "minimum": 248.22,
          "maximum": 865.4604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 605.8223,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 20FR 123120",
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        {
          "code": "3604629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 34.8527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12X150MM FE CFF71",
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        {
          "code": "3604631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 164.5253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X150MM FE CFF01",
      "code_information": [
        {
          "code": "3604632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X100MM BLADE CFB03",
      "code_information": [
        {
          "code": "3604633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.8733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 9MM 022109-10",
      "code_information": [
        {
          "code": "3604634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 10MM 022110-10",
      "code_information": [
        {
          "code": "3604635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 12MM 022112-10",
      "code_information": [
        {
          "code": "3604636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 47.6662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 14MM 022114-10",
      "code_information": [
        {
          "code": "3604637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 49.7164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 16MM 022116-10",
      "code_information": [
        {
          "code": "3604638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 54.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC 3-0 VLOCM0644",
      "code_information": [
        {
          "code": "3604653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 277.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO BULL M0068332451",
      "code_information": [
        {
          "code": "3604654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 273.1838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0 M0068331371",
      "code_information": [
        {
          "code": "3604655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 273.1838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-JP SUCT 10MM SU130-1311",
      "code_information": [
        {
          "code": "3604656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 10F SU130-402D",
      "code_information": [
        {
          "code": "3604657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 127,
          "minimum": 26.67,
          "maximum": 92.9894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 65.0926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MUSCLE-TRAINING DEVICE",
      "code_information": [
        {
          "code": "3604659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 169.1382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ACORN 5MM 5820-030-550",
      "code_information": [
        {
          "code": "3604667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 765.7348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERY 2X14MM 31200",
      "code_information": [
        {
          "code": "3604670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 452.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERY 1.5X14MM 31150",
      "code_information": [
        {
          "code": "3604671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 452.5728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCES 8MM IAS8-120LP",
      "code_information": [
        {
          "code": "3604725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 942,
          "minimum": 197.82,
          "maximum": 689.7324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 482.8127,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM ECS29B",
      "code_information": [
        {
          "code": "3604726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2143,
          "minimum": 450.03,
          "maximum": 1569.1046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1098.3732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOULDER LG/18-19.5\\\"\\\"",
      "code_information": [
        {
          "code": "3604728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 330.5883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOULDER M/16.5-18\\\"\\\"",
      "code_information": [
        {
          "code": "3604729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 330.5883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4MM 080-403",
      "code_information": [
        {
          "code": "3604730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 130.1852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LARGE COMBO AR-8964-07",
      "code_information": [
        {
          "code": "3604737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1732.2,
          "minimum": 363.762,
          "maximum": 1268.3168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 887.8218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN LG AR-8964-08",
      "code_information": [
        {
          "code": "3604738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1396.5,
          "minimum": 293.265,
          "maximum": 1022.5173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 715.7621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ATTACH-ROD LG CLMP AR-8964-09",
      "code_information": [
        {
          "code": "3604739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1309,
          "minimum": 274.89,
          "maximum": 958.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 670.9149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 100 AR-8964R-100",
      "code_information": [
        {
          "code": "3604740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591.5,
          "minimum": 124.215,
          "maximum": 433.0963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.1674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 250 AR-8964R-250",
      "code_information": [
        {
          "code": "3604741",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591.5,
          "minimum": 124.215,
          "maximum": 433.0963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.1674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 300 AR-8964R-300",
      "code_information": [
        {
          "code": "3604742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 665,
          "minimum": 139.65,
          "maximum": 486.913,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 340.8391,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 3.5X195MM AR-8964-10",
      "code_information": [
        {
          "code": "3604743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 332.5,
          "minimum": 69.825,
          "maximum": 243.4565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 170.4195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-END CAP AR-8964-22",
      "code_information": [
        {
          "code": "3604744",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REMV FIBULOCK AR-8973RK",
      "code_information": [
        {
          "code": "3604749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6093,
          "minimum": 1279.53,
          "maximum": 4461.2946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3122.9062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3604769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 534.0667,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LARGE COMBO AR-8964-07",
      "code_information": [
        {
          "code": "3604775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1702.6579,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN LG AR-8964-08",
      "code_information": [
        {
          "code": "3604776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1372.5821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ATTACH-ROD LG CLMP AR-8964-09",
      "code_information": [
        {
          "code": "3604777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2510,
          "minimum": 527.1,
          "maximum": 1837.822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1286.4754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 3.5X195MM AR-8964-10",
      "code_information": [
        {
          "code": "3604781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 508.4397,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-END CAP AR-8964-22",
      "code_information": [
        {
          "code": "3604782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD CTR/25MM MWJ005",
      "code_information": [
        {
          "code": "3604783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5858,
          "minimum": 1230.18,
          "maximum": 4289.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3002.4593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3X215MM 542053",
      "code_information": [
        {
          "code": "3604785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1886,
          "minimum": 396.06,
          "maximum": 1380.9292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 966.6504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X215MM 542051",
      "code_information": [
        {
          "code": "3604786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1776,
          "minimum": 372.96,
          "maximum": 1300.3872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 910.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPM-SOFT GOODS",
      "code_information": [
        {
          "code": "3604787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 166.5755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBGAUZE*SURGITUBE SZ 5/8\\\"",
      "code_information": [
        {
          "code": "3604794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.7807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR XS 11MM 10/BX",
      "code_information": [
        {
          "code": "3604795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 592,
          "minimum": 124.32,
          "maximum": 433.4624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 303.4237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR Y 1/4x1/4x1/4",
      "code_information": [
        {
          "code": "3604798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.1427,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO HF 125 AR-3210-0052",
      "code_information": [
        {
          "code": "3604799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 696.5,
          "minimum": 146.265,
          "maximum": 509.9773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 356.9841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.5X215MM 542021",
      "code_information": [
        {
          "code": "3604823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1885,
          "minimum": 395.85,
          "maximum": 1380.197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 966.1379,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT AO 93MM 542031",
      "code_information": [
        {
          "code": "3604824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3667,
          "minimum": 770.07,
          "maximum": 2684.9774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1879.4842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT AO 180MM 542032",
      "code_information": [
        {
          "code": "3604825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2024.0205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 3.5X135MM 542022",
      "code_information": [
        {
          "code": "3604832",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1664,
          "minimum": 349.44,
          "maximum": 1218.3808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 852.8666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165 AR-9095-43S",
      "code_information": [
        {
          "code": "3604868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1941,
          "minimum": 407.61,
          "maximum": 1421.2002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 994.8401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SX DRY 13CM PSS13DF-5",
      "code_information": [
        {
          "code": "3604876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1671,
          "minimum": 350.91,
          "maximum": 1223.5062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 856.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD T-MAX 7210559",
      "code_information": [
        {
          "code": "3604877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 205.5285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 542000",
      "code_information": [
        {
          "code": "3604891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1626,
          "minimum": 341.46,
          "maximum": 1190.5572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 833.39,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER 60-6085-201A",
      "code_information": [
        {
          "code": "3604912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 435.659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XL/19.5-22\\\"\\\"",
      "code_information": [
        {
          "code": "3604916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 330.5883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH 6MM NIM 8229706",
      "code_information": [
        {
          "code": "3604917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1414.0979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH 8MM NIM 8229708",
      "code_information": [
        {
          "code": "3604918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1414.0979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-LEAD 518-024",
      "code_information": [
        {
          "code": "3604919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 588.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-BULLDOG LEAD LR-LED01",
      "code_information": [
        {
          "code": "3604933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2457,
          "minimum": 515.97,
          "maximum": 1799.0154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1259.3108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 7X7 AR-6570TD",
      "code_information": [
        {
          "code": "3604936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 205.5285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X125MM 542002",
      "code_information": [
        {
          "code": "3604942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1702,
          "minimum": 357.42,
          "maximum": 1246.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 872.3431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-NEURO PDCMF-BP-001",
      "code_information": [
        {
          "code": "3604949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 946.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRITOME 3WAY SN31",
      "code_information": [
        {
          "code": "3604952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1358.7435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEXUS CONNECTORS BP6866N",
      "code_information": [
        {
          "code": "3604957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 98.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-LEG SM/16-20\\\"\\\" LS101",
      "code_information": [
        {
          "code": "3604958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 302.9111,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 5-0 VCP834G",
      "code_information": [
        {
          "code": "3604959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 42.0283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-SINSKEY 45 /10MM 581442",
      "code_information": [
        {
          "code": "3604965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 371,
          "minimum": 77.91,
          "maximum": 271.6462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 190.1523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-AGILIS HISPRO DS3A001",
      "code_information": [
        {
          "code": "3604978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.2417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LONG INSERTION 40555",
      "code_information": [
        {
          "code": "3604987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3349,
          "minimum": 703.29,
          "maximum": 2452.1378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1716.4965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY VIAL HH9006",
      "code_information": [
        {
          "code": "3604989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3536,
          "minimum": 742.56,
          "maximum": 2589.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1812.3414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRL 4MM CLOSED AR-1595TC",
      "code_information": [
        {
          "code": "3605014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 702.6923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.5X250 SQC 76-10047",
      "code_information": [
        {
          "code": "3605028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2009,
          "minimum": 421.89,
          "maximum": 1470.9898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1029.6929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM CENTERING 76-10210",
      "code_information": [
        {
          "code": "3605029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 934,
          "minimum": 196.14,
          "maximum": 683.8748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 478.7124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 5H 76-10145",
      "code_information": [
        {
          "code": "3605031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 867.2177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-6X8MM RANCHO 76-10165",
      "code_information": [
        {
          "code": "3605032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 192.715,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-180MM BUTT 71-61180",
      "code_information": [
        {
          "code": "3605034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 867.2177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-150MM BUTT 71-61150",
      "code_information": [
        {
          "code": "3605035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 867.2177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARCH-FOOT 150MM 71-90150",
      "code_information": [
        {
          "code": "3605036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5854,
          "minimum": 1229.34,
          "maximum": 4286.2988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3000.4092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FOOT 150MM LONG 71-6100L",
      "code_information": [
        {
          "code": "3605037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9905,
          "minimum": 2080.05,
          "maximum": 7252.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 5076.7087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 155MM 71-10155",
      "code_information": [
        {
          "code": "3605038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6752,
          "minimum": 1417.92,
          "maximum": 4943.8144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3460.6701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 ETHIBOND 10X86N",
      "code_information": [
        {
          "code": "3605039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 484,
          "minimum": 101.64,
          "maximum": 354.3848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 248.0694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-STONE COLLECT XUSM0031",
      "code_information": [
        {
          "code": "3605040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 503,
          "minimum": 105.63,
          "maximum": 368.2966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.8076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AP LNG/LT AR-8954-10",
      "code_information": [
        {
          "code": "3605076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3379,
          "minimum": 709.59,
          "maximum": 2474.1038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1731.8727,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-GIGLI SAW 260-104",
      "code_information": [
        {
          "code": "3605086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IMPELLA AXILLARY 0052-0011",
      "code_information": [
        {
          "code": "3605088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURESTEP MALE EXT CATH",
      "code_information": [
        {
          "code": "3605089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURESTEP MALE EXT CATH",
      "code_information": [
        {
          "code": "3605090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.9029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV 22G X 2.5\\\" 4251622-02",
      "code_information": [
        {
          "code": "3605091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 68.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TPR 3.2/3.9X450 1420-0065S",
      "code_information": [
        {
          "code": "3605102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 652.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNAL #6 14\\\" 040-365",
      "code_information": [
        {
          "code": "3605111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1245,
          "minimum": 261.45,
          "maximum": 911.589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 638.1123,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EXT 1.2 MICRON FILTER",
      "code_information": [
        {
          "code": "3605116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 35.3653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO ST 90 AR-4068-90",
      "code_information": [
        {
          "code": "3605127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 786.7489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP EXT 6.2/3.2",
      "code_information": [
        {
          "code": "3605137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP NORM 4.9/2.2",
      "code_information": [
        {
          "code": "3605138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-HIP S5/38.5X105 7000-6605",
      "code_information": [
        {
          "code": "3699561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7456,
          "minimum": 1565.76,
          "maximum": 5459.2832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 3821.4982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-JEWETT TLSO S/M REGULAR",
      "code_information": [
        {
          "code": "3699634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 698.0795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 15M",
      "code_information": [
        {
          "code": "3700007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3512,
          "minimum": 737.52,
          "maximum": 2571.4864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1800.0405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORPREP    260700",
      "code_information": [
        {
          "code": "3800580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 27.6772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORQUE-DEVICE           46-550",
      "code_information": [
        {
          "code": "3801395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-18G BARE NEEDLE 78060",
      "code_information": [
        {
          "code": "3820010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1115,
          "minimum": 234.15,
          "maximum": 816.403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 571.4821,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 18X6     618735",
      "code_information": [
        {
          "code": "3820055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2797,
          "minimum": 587.37,
          "maximum": 2047.9634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1433.5744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 22X6     618743",
      "code_information": [
        {
          "code": "3820057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1434.5995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 25x6 611771",
      "code_information": [
        {
          "code": "3820062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3718,
          "minimum": 780.78,
          "maximum": 2722.3196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1905.6237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BACKSTOP                MBS100",
      "code_information": [
        {
          "code": "3820086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.1788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-SURGICAL PACEDISP 5833SL",
      "code_information": [
        {
          "code": "3820163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 357,
          "minimum": 74.97,
          "maximum": 261.3954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 182.9768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING DISP         6651",
      "code_information": [
        {
          "code": "3820222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACEMAKER           6697",
      "code_information": [
        {
          "code": "3820223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 183.4893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING         FL-601-97",
      "code_information": [
        {
          "code": "3820226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD                  6623",
      "code_information": [
        {
          "code": "3820227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.8765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON WEDGE PRESSURE",
      "code_information": [
        {
          "code": "3820550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 492.5509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ATH-GUIDE 8F",
      "code_information": [
        {
          "code": "3821029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUIDE 6FR",
      "code_information": [
        {
          "code": "3821056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUIDE 6F",
      "code_information": [
        {
          "code": "3821057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUID 7FR",
      "code_information": [
        {
          "code": "3821245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 162,
          "minimum": 34.02,
          "maximum": 118.6164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 83.0315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOGRAM,BALLOON     6215",
      "code_information": [
        {
          "code": "3823025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.0918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION      04527-05",
      "code_information": [
        {
          "code": "3823418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 581,
          "minimum": 122.01,
          "maximum": 425.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 297.7857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-COPILOT         1003331",
      "code_information": [
        {
          "code": "3823422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP    XX*RF0xx",
      "code_information": [
        {
          "code": "3823429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 214.7543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE           MAP500",
      "code_information": [
        {
          "code": "3823431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-SAFEGUARD PRES  D82000D",
      "code_information": [
        {
          "code": "3823437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 738,
          "minimum": 154.98,
          "maximum": 540.3636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 378.2545,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP 24CM   3524",
      "code_information": [
        {
          "code": "3823443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL 5FR 20CM G00972",
      "code_information": [
        {
          "code": "3823451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-STATLOCK   D684000472",
      "code_information": [
        {
          "code": "3823520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 270,
          "minimum": 56.7,
          "maximum": 197.694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 138.3858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENVELOPE-TYRX ABSORB CMRM6133",
      "code_information": [
        {
          "code": "3823584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2587.8145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAGONFLY OPTIS    C40864x",
      "code_information": [
        {
          "code": "3824115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3181,
          "minimum": 668.01,
          "maximum": 2329.1282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1630.3897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION          LNQTOOL",
      "code_information": [
        {
          "code": "3824170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 423.8706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION  D884-00-0019-13",
      "code_information": [
        {
          "code": "3824174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 603.2596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION  D884-00-0019-17",
      "code_information": [
        {
          "code": "3824175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 603.2596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACCESSORY     518-027",
      "code_information": [
        {
          "code": "3824178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1514,
          "minimum": 317.94,
          "maximum": 1108.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 775.9856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INJECTION     ART700SYR",
      "code_information": [
        {
          "code": "3824179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 85.0816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC 17L         6056M",
      "code_information": [
        {
          "code": "3824181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD CAP           5867-3M",
      "code_information": [
        {
          "code": "3824183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 344,
          "minimum": 72.24,
          "maximum": 251.8768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 176.3138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INTELL SYR   K05-00626F",
      "code_information": [
        {
          "code": "3824184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.2358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURGIFLO 8ML          2991",
      "code_information": [
        {
          "code": "3824205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1355,
          "minimum": 284.55,
          "maximum": 992.131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 694.4917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET             6057-45",
      "code_information": [
        {
          "code": "3824219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SERVICE WRENCH       5873W",
      "code_information": [
        {
          "code": "3824221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 526,
          "minimum": 110.46,
          "maximum": 385.1372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 269.596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PINCH-ON-TOOL         6056",
      "code_information": [
        {
          "code": "3824225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET PACEMAKER   60xx-xx",
      "code_information": [
        {
          "code": "3824226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET             6091-53",
      "code_information": [
        {
          "code": "3824228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 195.7903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE  23548-001",
      "code_information": [
        {
          "code": "3824246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 927,
          "minimum": 194.67,
          "maximum": 678.7494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 475.1246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-THREE PORT 203BN-R",
      "code_information": [
        {
          "code": "3824285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 38.4405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MULTIPAC-4FR SHEATH   538-493P",
      "code_information": [
        {
          "code": "3824294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 213.7292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-18G BARE          78050",
      "code_information": [
        {
          "code": "3824350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1037,
          "minimum": 217.77,
          "maximum": 759.2914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 531.504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSEPTAL BRK-1 407201",
      "code_information": [
        {
          "code": "3824358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1765,
          "minimum": 370.65,
          "maximum": 1292.333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 904.6331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSEPTAL       G02364",
      "code_information": [
        {
          "code": "3824360",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1241,
          "minimum": 260.61,
          "maximum": 908.6602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 636.0621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV FINAL    DS2C01",
      "code_information": [
        {
          "code": "3824368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 669.3772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER  DS2A003",
      "code_information": [
        {
          "code": "3824369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 409,
          "minimum": 85.89,
          "maximum": 299.4698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 209.6289,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-D-STAT DRY CLEAR    3005",
      "code_information": [
        {
          "code": "3824415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DEFIBRILLATOR        6998",
      "code_information": [
        {
          "code": "3824426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 423.8706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-PIN DF-1             6996",
      "code_information": [
        {
          "code": "3824428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 178.8765,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING SMARTABLATE  SAT001",
      "code_information": [
        {
          "code": "3824441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 492.5509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICROPUNCTURE     S-MAK401",
      "code_information": [
        {
          "code": "3824445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 427,
          "minimum": 89.67,
          "maximum": 312.6494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 218.8546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GLIDE 6FR   RM*BF6M10MA",
      "code_information": [
        {
          "code": "3824476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 456,
          "minimum": 95.76,
          "maximum": 333.8832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 233.7182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-SAFE ALL SZS CLS-10xx.x",
      "code_information": [
        {
          "code": "3824605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INTRODUCER     CLS-250x",
      "code_information": [
        {
          "code": "3824621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 359,
          "minimum": 75.39,
          "maximum": 262.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 184.0019,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J426H",
      "code_information": [
        {
          "code": "3824635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-INJECTOR 150 C853-6150",
      "code_information": [
        {
          "code": "3824642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 45.1035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 27\\\"    J427H",
      "code_information": [
        {
          "code": "3824649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.7775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMAX ADHESIVE MAXA",
      "code_information": [
        {
          "code": "3824663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 123.5221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-STATLOCK PSI 0684-00-'s",
      "code_information": [
        {
          "code": "3824681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 317,
          "minimum": 66.57,
          "maximum": 232.1074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 162.4752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXR35",
      "code_information": [
        {
          "code": "3824705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-UNIVERSAL      6232ADJ",
      "code_information": [
        {
          "code": "3824709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-UNIVERSAL      6230UNI",
      "code_information": [
        {
          "code": "3824710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-CONNECTOR PSA EX3151",
      "code_information": [
        {
          "code": "3824711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1045,
          "minimum": 219.45,
          "maximum": 765.149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 535.6043,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STERILE 30CM     406500",
      "code_information": [
        {
          "code": "3824713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 73.8058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRT XSOFT 59CM 5005",
      "code_information": [
        {
          "code": "3824883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-LONG SOFT 59CM 5014",
      "code_information": [
        {
          "code": "3824884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 305.9864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-RUST            6054-58",
      "code_information": [
        {
          "code": "3824889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 163.5003,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CONTROL 20ML    CCS320",
      "code_information": [
        {
          "code": "3824955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 32.8026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLUID WASTE    64000936",
      "code_information": [
        {
          "code": "3824996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 152.7369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-FLEXTEND FIXATION    6616",
      "code_information": [
        {
          "code": "3825028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-CONTRAST        HPF480K",
      "code_information": [
        {
          "code": "3825032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 43.5659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PASSAGE HEMOSTAS  MAP112",
      "code_information": [
        {
          "code": "3825048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 101.4829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             6628",
      "code_information": [
        {
          "code": "3825085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 255.2449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-GLIDEWIRE INSERT   MAP550",
      "code_information": [
        {
          "code": "3825086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 29.2148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HIGH PRES 20\\\"   HPF200E",
      "code_information": [
        {
          "code": "3825097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 39.4656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDAL MICROPUNCTURE G02972",
      "code_information": [
        {
          "code": "3825123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 717,
          "minimum": 150.57,
          "maximum": 524.9874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 367.4912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-PACEMAKER ALL",
      "code_information": [
        {
          "code": "3825190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 306.4989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.0X150MM 390142",
      "code_information": [
        {
          "code": "3900001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150MM SS 390162",
      "code_information": [
        {
          "code": "3900002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 72.2681,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X55X32MM 608455",
      "code_information": [
        {
          "code": "3900059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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        {
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        }
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          ]
        }
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        },
        {
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        }
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        {
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          ]
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        },
        {
          "code": "0270",
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        }
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          ]
        }
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        {
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        {
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          ]
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        }
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          ]
        }
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        {
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        }
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    {
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          ]
        }
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        {
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X7MM 662507",
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        {
          "code": "3900240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 211.05,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X9MM 662509",
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        {
          "code": "3900241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 211.05,
          "maximum": 735.861,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X14MM 663714",
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        {
          "code": "3900242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 211.05,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X15MM 663715",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 211.05,
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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        }
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.3X24MM 663724",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.3X26MM 663726",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    {
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        },
        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.4X32MM 656032",
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        },
        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.4X34MM 656034",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.4X8MM 656008",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
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        },
        {
          "code": "0270",
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        }
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        {
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        }
      ],
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        },
        {
          "code": "0270",
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        }
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          ]
        }
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    {
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        },
        {
          "code": "0270",
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        }
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        {
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            }
          ]
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        {
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
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          ]
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      ],
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    },
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        },
        {
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        }
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          ]
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        {
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          ]
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        {
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        }
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          ]
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        {
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    },
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          ]
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      ],
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    },
    {
      "description": "SCREW-CANN 8.0X70MM 611070",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X14MM 657614",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 202.86,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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          "code": "3900301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X26MM 657626",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
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          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
      ],
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    {
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        {
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          ]
        }
      ],
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    {
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        {
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          ]
        }
      ],
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    },
    {
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        {
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          ]
        }
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    },
    {
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        {
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          ]
        }
      ],
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    },
    {
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        {
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        }
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
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        {
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    {
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    {
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        {
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
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        {
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        }
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              "payer_name": "Anthem",
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            }
          ]
        }
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    {
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        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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          ]
        }
      ],
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    {
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        },
        {
          "code": "0270",
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        }
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        {
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              "payer_name": "Anthem",
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          ]
        }
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    {
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        {
          "code": "0270",
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        }
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        {
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          ]
        }
      ],
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    {
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        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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          ]
        }
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    {
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        {
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          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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          ]
        }
      ],
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    {
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        {
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            }
          ]
        }
      ],
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    {
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        {
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          ]
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        {
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    {
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        {
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    {
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        },
        {
          "code": "0270",
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        }
      ],
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-ROD TO ROD 4960-1-010",
      "code_information": [
        {
          "code": "3900424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2857,
          "minimum": 599.97,
          "maximum": 2091.8954,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN 4960-2-020",
      "code_information": [
        {
          "code": "3900425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 599.97,
          "maximum": 2091.8954,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1464.3268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN 90° 4960-2-030",
      "code_information": [
        {
          "code": "3900426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 599.97,
          "maximum": 2091.8954,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-ROD TO ROD 4960-1-060",
      "code_information": [
        {
          "code": "3900427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "gross_charge": 3232,
          "minimum": 678.72,
          "maximum": 2366.4704,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1656.5293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 12H/143MM",
      "code_information": [
        {
          "code": "3900428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3412,
          "minimum": 716.52,
          "maximum": 2498.2664,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1748.7865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/1.7MM 57-10304",
      "code_information": [
        {
          "code": "3900429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-15301",
      "code_information": [
        {
          "code": "3900430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "gross_charge": 3728,
          "minimum": 782.88,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1910.7491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-15302",
      "code_information": [
        {
          "code": "3900431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1910.7491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/LT 57-10321",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1910.7491,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/RT 57-10320",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1910.7491,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1910.7491,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/RT 57-15320",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 1048.11,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 2558.0871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 6H/1.7MM 57-10340",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1656.5293,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3D 2X2+2H 57-10197",
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          "code": "3900438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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          "payers_information": [
            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3D 4X2H 57-10195",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/2.3MM 57-10191",
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        },
        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 13H/2.3 57-10179",
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        },
        {
          "code": "0270",
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        }
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 10H/2X54MM 629610",
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        },
        {
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        }
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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        }
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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    {
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      ],
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    {
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        },
        {
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          ]
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      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "standard_charge_dollar": 2234.6744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-PIN TO ROD 4922-1-030",
      "code_information": [
        {
          "code": "3900452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2234.6744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-ROD TO ROD 4922-1-010",
      "code_information": [
        {
          "code": "3900453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2234.6744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 20H/2.4X132MM 629680",
      "code_information": [
        {
          "code": "3900454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2234.6744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-PIN 5H 4922-2-020",
      "code_information": [
        {
          "code": "3900455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2558.0871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3MM 57-10185",
      "code_information": [
        {
          "code": "3900456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2558.0871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3MM 57-13185",
      "code_information": [
        {
          "code": "3900457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2558.0871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 16H/1.7MM 57-10316",
      "code_information": [
        {
          "code": "3900458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2558.0871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2+2H/1.7 57-10397",
      "code_information": [
        {
          "code": "3900459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5623,
          "minimum": 1180.83,
          "maximum": 4117.1606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2882.0124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/1.7 57-10390",
      "code_information": [
        {
          "code": "3900460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2558.0871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/2.3 57-15390",
      "code_information": [
        {
          "code": "3900461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2558.0871,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 9H/1.7MM 57-10379",
      "code_information": [
        {
          "code": "3900474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 14H/167MM",
      "code_information": [
        {
          "code": "3900475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 16H/191MM",
      "code_information": [
        {
          "code": "3900476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 10H/2X57MM 629630",
      "code_information": [
        {
          "code": "3900477",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 6H/2X34MM 629626",
      "code_information": [
        {
          "code": "3900478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 8H/2X46MM 629628",
      "code_information": [
        {
          "code": "3900479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2X23MM 629624",
      "code_information": [
        {
          "code": "3900480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 10H 629560",
      "code_information": [
        {
          "code": "3900481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 9H 629559",
      "code_information": [
        {
          "code": "3900482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 10H 629510",
      "code_information": [
        {
          "code": "3900483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 8H 629548",
      "code_information": [
        {
          "code": "3900484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR LONG LT 54-25405",
      "code_information": [
        {
          "code": "3900499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR LONG RT 54-25404",
      "code_information": [
        {
          "code": "3900500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR SHORT LT 54-25403",
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        {
          "code": "3900501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR SHORT RT 54-25402",
      "code_information": [
        {
          "code": "3900502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 227.22,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.4X69MM 629690",
      "code_information": [
        {
          "code": "3900503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2.4X28 629684",
      "code_information": [
        {
          "code": "3900504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2.4X41MM 629686",
      "code_information": [
        {
          "code": "3900505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.4X56MM 629688",
      "code_information": [
        {
          "code": "3900506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/150MM 629512",
      "code_information": [
        {
          "code": "3900507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/174MM 629514",
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        {
          "code": "3900508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 11H 629561",
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        {
          "code": "3900509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 12H 629562",
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        {
          "code": "3900510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 14H 629564",
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        {
          "code": "3900511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.4X80 629710",
      "code_information": [
        {
          "code": "3900512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X5H/2.7X47MM 629784",
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        {
          "code": "3900530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 5X10H/2.7X87MM 629787",
      "code_information": [
        {
          "code": "3900531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TRI 10H/2.4X81MM 629791",
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        {
          "code": "3900532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-Y 10H/2.4X81MM 629790",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 12H/2.7X108 629752",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 14H/2.7X125 629754",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL STD LT 54-25291",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 554.5683,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL STD RT 54-25290",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL WIDE LT 54-25293",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-HUM 3H/80MM/LT 628303",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-HUM 3H/80MM/RT 629323",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-HUM 3H/80MM/RT/629263",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-HUM 3H/84MM/LT 629203",
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        },
        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 3H 629283",
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          "type": "LOCAL"
        },
        {
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        }
      ],
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            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-T 10H/2.7X92MM 629788",
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        },
        {
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 291.06,
          "maximum": 1014.8292,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 710.3804,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-TRI 10H/2.7X92MM 629789",
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        },
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        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
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        }
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            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-DEC 6H/75MM/LT 628006",
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          "code": "3900549",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-HUM 4H/105MM/LT 629244",
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        {
          "code": "3900550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "PLATE-HUM 4H/109MM/LT 629204",
      "code_information": [
        {
          "code": "3900551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 710.3804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/109MM/RT 629204",
      "code_information": [
        {
          "code": "3900552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 710.3804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/LT 629304",
      "code_information": [
        {
          "code": "3900553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 710.3804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/RT 629324",
      "code_information": [
        {
          "code": "3900554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 710.3804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/128MM/RT 629266",
      "code_information": [
        {
          "code": "3900555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/132MM /RT 629226",
      "code_information": [
        {
          "code": "3900556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/132MM/LT 629206",
      "code_information": [
        {
          "code": "3900557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/LT 629306",
      "code_information": [
        {
          "code": "3900558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/RT 629326",
      "code_information": [
        {
          "code": "3900559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 4H 629284",
      "code_information": [
        {
          "code": "3900560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 6H 629286",
      "code_information": [
        {
          "code": "3900561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-OLE 6H/113MM/LT 629346",
      "code_information": [
        {
          "code": "3900562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/71MM/RT 627734",
      "code_information": [
        {
          "code": "3900563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 12H/76MM/RT 54-25385",
      "code_information": [
        {
          "code": "3900564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 14H/76MM/LT 54-25377",
      "code_information": [
        {
          "code": "3900565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 14H/76MM/RT 54-25387",
      "code_information": [
        {
          "code": "3900566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG 54-25296",
      "code_information": [
        {
          "code": "3900567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG 54-25297",
      "code_information": [
        {
          "code": "3900568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG LT 54-25295",
      "code_information": [
        {
          "code": "3900569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG RT 54-25294",
      "code_information": [
        {
          "code": "3900570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 5H/84MM/LT 627705",
      "code_information": [
        {
          "code": "3900571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 5H/84MM/RT 627735",
      "code_information": [
        {
          "code": "3900572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 5H/5X97MM 627535",
      "code_information": [
        {
          "code": "3900573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/5X115MM 627536",
      "code_information": [
        {
          "code": "3900574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/5X119MM 627566",
      "code_information": [
        {
          "code": "3900575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 6H/97MM/LT 627706",
      "code_information": [
        {
          "code": "3900576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/97MM/LT 627404",
      "code_information": [
        {
          "code": "3900577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/97MM/RT 627434",
      "code_information": [
        {
          "code": "3900578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 713.4557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/123MM/LT 627708",
      "code_information": [
        {
          "code": "3900579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 6H 628406",
      "code_information": [
        {
          "code": "3900580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 7 H 628407",
      "code_information": [
        {
          "code": "3900581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 8 H 628408",
      "code_information": [
        {
          "code": "3900582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 10H 628310",
      "code_information": [
        {
          "code": "3900583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 7 H 628307",
      "code_information": [
        {
          "code": "3900584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 8 H 628308",
      "code_information": [
        {
          "code": "3900585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 10H/120MM/RT 628130",
      "code_information": [
        {
          "code": "3900586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 8H/97MM/LT 628108",
      "code_information": [
        {
          "code": "3900587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 8H/97MM/RT 628128",
      "code_information": [
        {
          "code": "3900588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 560.7188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 11H/5X209MM 627571",
      "code_information": [
        {
          "code": "3900590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 825.1894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/5X223MM 627542",
      "code_information": [
        {
          "code": "3900591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 825.1894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/5X227MM 627572",
      "code_information": [
        {
          "code": "3900592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 825.1894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 8H/5X155MM 627568",
      "code_information": [
        {
          "code": "3900593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1153.7275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 9H/5X173MM 627569",
      "code_information": [
        {
          "code": "3900594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1153.7275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/102MM RT 627484",
      "code_information": [
        {
          "code": "3900595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1153.7275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/102MM/LT 627454",
      "code_information": [
        {
          "code": "3900596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1153.7275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 13H/5X245MM 627573",
      "code_information": [
        {
          "code": "3900597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1770,
          "minimum": 371.7,
          "maximum": 1295.994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 907.1958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/5X259MM 627544",
      "code_information": [
        {
          "code": "3900598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2855,
          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1463.3017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/5X263MM 627574",
      "code_information": [
        {
          "code": "3900599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1046.6067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 6H/127MM/LT 627456",
      "code_information": [
        {
          "code": "3900600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1046.6067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/121MM/LT 627304",
      "code_information": [
        {
          "code": "3900601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1046.6067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/153MM/RT 627488",
      "code_information": [
        {
          "code": "3900602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1046.6067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/178MM/LT 627460",
      "code_information": [
        {
          "code": "3900603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1433.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 6H/RT 628166",
      "code_information": [
        {
          "code": "3900608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 8H/LT 628148",
      "code_information": [
        {
          "code": "3900609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 8H/RT 628168",
      "code_information": [
        {
          "code": "3900610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/199MM/LT 627310",
      "code_information": [
        {
          "code": "3900611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/199MM/RT 627340",
      "code_information": [
        {
          "code": "3900612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 12H/225MM/LT 627312",
      "code_information": [
        {
          "code": "3900613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 12H/225MM/RT 627342",
      "code_information": [
        {
          "code": "3900614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/139MM 629388",
      "code_information": [
        {
          "code": "3900615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/150MM/LT 629248",
      "code_information": [
        {
          "code": "3900616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1244.9597,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/156MM/LT 629208",
      "code_information": [
        {
          "code": "3900617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/156MM/RT 629228",
      "code_information": [
        {
          "code": "3900618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/LT 629308",
      "code_information": [
        {
          "code": "3900619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/RT 629328",
      "code_information": [
        {
          "code": "3900620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 8H 629288",
      "code_information": [
        {
          "code": "3900621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-OLE 8H/137MM/LT 629348",
      "code_information": [
        {
          "code": "3900622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 14H/251MM/LT 627314",
      "code_information": [
        {
          "code": "3900623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 14H/251MM/RT 627344",
      "code_information": [
        {
          "code": "3900624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 7H/122/LT 628207",
      "code_information": [
        {
          "code": "3900625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 7H/122/RT 628227",
      "code_information": [
        {
          "code": "3900626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 981.5141,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 10H/176MM/RT 627240",
      "code_information": [
        {
          "code": "3900627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1433.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/151MM/LT 627208",
      "code_information": [
        {
          "code": "3900628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1433.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 4H/130MM/RT 627634",
      "code_information": [
        {
          "code": "3900630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1433.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 14H/310MM/LT 627614",
      "code_information": [
        {
          "code": "3900636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 411,
          "minimum": 86.31,
          "maximum": 300.9342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 210.6539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 14H/310MM/RT 627644",
      "code_information": [
        {
          "code": "3900637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 411,
          "minimum": 86.31,
          "maximum": 300.9342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 210.6539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 16H/343MM/RT 627646",
      "code_information": [
        {
          "code": "3900638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 564.8191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-GAIT UNIVERSAL M2616D01",
      "code_information": [
        {
          "code": "4432470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 48.6913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IC SILVER 16FR 30CC SI16",
      "code_information": [
        {
          "code": "4433340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.1929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN FOLEY 12 FR 5CC",
      "code_information": [
        {
          "code": "4435701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 111.2212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENIPUNCTURE STIK-GUARD",
      "code_information": [
        {
          "code": "4445500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 44.591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYMEM 3X1",
      "code_information": [
        {
          "code": "4452250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 31.2649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEN 4X12 1/2 5124",
      "code_information": [
        {
          "code": "4454125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 81.4939,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EXT MIC-KEY 0121-24",
      "code_information": [
        {
          "code": "4455449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 77.9061,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-DISP SLIPTIP DX",
      "code_information": [
        {
          "code": "4458390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 36.3903,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-EBUS          MAJ-1351",
      "code_information": [
        {
          "code": "4820147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 198.8655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RAPID REFILL INJECTION",
      "code_information": [
        {
          "code": "4820306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 335,
          "minimum": 70.35,
          "maximum": 245.287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 171.7009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RX DELIVERY 10FR",
      "code_information": [
        {
          "code": "4820316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.2358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHOTRIPTER RX",
      "code_information": [
        {
          "code": "4820525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 877.4685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL PULM 0 12/120",
      "code_information": [
        {
          "code": "4820546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1671,
          "minimum": 350.91,
          "maximum": 1223.5062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 856.4543,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CLEANING          000336",
      "code_information": [
        {
          "code": "4820730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 137.3607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CLEANING 1-1.5MMX1650MM",
      "code_information": [
        {
          "code": "4820735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 132,
          "minimum": 27.72,
          "maximum": 96.6504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 67.6553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY BARD     000107",
      "code_information": [
        {
          "code": "4820950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 98.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY RX",
      "code_information": [
        {
          "code": "4821045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 557.6435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-MICRO BIOLOGY        130",
      "code_information": [
        {
          "code": "4821100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 139.4109,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G TUBE ALL SIZES",
      "code_information": [
        {
          "code": "4821257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1029,
          "minimum": 216.09,
          "maximum": 753.4338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 527.4037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TAPER TIP RX      4577",
      "code_information": [
        {
          "code": "4821690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 878,
          "minimum": 184.38,
          "maximum": 642.8716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 450.0101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO PH     9012B1011",
      "code_information": [
        {
          "code": "4821720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 997.9154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-TWISTER PLUS 26MM",
      "code_information": [
        {
          "code": "4822220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 382.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTAT RESOLUTION",
      "code_information": [
        {
          "code": "4822320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 669.3772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LOCKING ERCP RX    4526",
      "code_information": [
        {
          "code": "4822475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.2321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP  RJ4 1333-4",
      "code_information": [
        {
          "code": "4823705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 89.6945,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY SUPERTRAX",
      "code_information": [
        {
          "code": "4823755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 382.8674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW DISP 1550-40",
      "code_information": [
        {
          "code": "4823800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 275,
          "minimum": 57.75,
          "maximum": 201.355,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 140.9485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ANGIOGRAPHIC CATHETER",
      "code_information": [
        {
          "code": "4824510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 658.1014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDER-SPEED SUPERVIEW 7  4225",
      "code_information": [
        {
          "code": "4824650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1655,
          "minimum": 347.55,
          "maximum": 1211.791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 848.2537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-MULTIBITE 240 CM   1012",
      "code_information": [
        {
          "code": "4825400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 228.0803,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-400Y-0423",
      "code_information": [
        {
          "code": "4825501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR   NM-400L-0525",
      "code_information": [
        {
          "code": "4825519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GAUGE EBUS",
      "code_information": [
        {
          "code": "4825530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 435.659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GAUGE EBUS",
      "code_information": [
        {
          "code": "4825535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 589.421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EXCELON  19G",
      "code_information": [
        {
          "code": "4825654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 459.2358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-NEEDLE RX F/G",
      "code_information": [
        {
          "code": "4825690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-WANG              MW319",
      "code_information": [
        {
          "code": "4825700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 580,
          "minimum": 121.8,
          "maximum": 424.676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 297.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTION 25GA",
      "code_information": [
        {
          "code": "4825701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 383,
          "minimum": 80.43,
          "maximum": 280.4326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 196.3028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-FOOD BOLUS ROTH   00711155",
      "code_information": [
        {
          "code": "4825703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 915,
          "minimum": 192.15,
          "maximum": 669.963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 468.9741,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-ROTATING RETRIVAL 00711050",
      "code_information": [
        {
          "code": "4825705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 463.3362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 1.5MM 4.5FR 150CM",
      "code_information": [
        {
          "code": "4825995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 803.1502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD 7 FR           6007",
      "code_information": [
        {
          "code": "4826050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1249,
          "minimum": 262.29,
          "maximum": 914.5178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 640.1625,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-CATHETER MANOSHIELD",
      "code_information": [
        {
          "code": "4826655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL STD 240CM      6232",
      "code_information": [
        {
          "code": "4827202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 103.5331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-DISP HEXAGON CAPTIVATOR",
      "code_information": [
        {
          "code": "4827315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 107.1209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-POLYP 00711099",
      "code_information": [
        {
          "code": "4828705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 170,
          "minimum": 35.7,
          "maximum": 124.474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 87.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLON DECOMP  CDSG-14-175",
      "code_information": [
        {
          "code": "4829170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1525,
          "minimum": 320.25,
          "maximum": 1116.605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 781.6235,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 14FR 0100-14LV",
      "code_information": [
        {
          "code": "4829260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 193.7401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22 FR  0100-22",
      "code_information": [
        {
          "code": "4829300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.69,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 24 FR  0100-24",
      "code_information": [
        {
          "code": "4829350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 193.7401,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 26 FR  0100-26",
      "code_information": [
        {
          "code": "4829400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 199.3781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10 FR 30-7361",
      "code_information": [
        {
          "code": "4829700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 220.9047,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION ENDOGATOR",
      "code_information": [
        {
          "code": "4829895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 74.8308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-AQUAPLAST 12X18 3.2MM",
      "code_information": [
        {
          "code": "5699102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 9X12 MT-APU-12",
      "code_information": [
        {
          "code": "5750063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 199.3781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-PROBE PROSTATE   613-245",
      "code_information": [
        {
          "code": "5995267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BARD BIOPSY 12G     121210",
      "code_information": [
        {
          "code": "5995268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 332.6385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE ENDOCAVITY",
      "code_information": [
        {
          "code": "5995272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 253,
          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 129.6726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE ULTRA PRO II",
      "code_information": [
        {
          "code": "5995273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 160.425,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ULTRASOUND 12GX12CM",
      "code_information": [
        {
          "code": "5995304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 860.0421,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY ALL SZS",
      "code_information": [
        {
          "code": "5995532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 514,
          "minimum": 107.94,
          "maximum": 376.3508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 263.4456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY 14X10",
      "code_information": [
        {
          "code": "5995534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 545,
          "minimum": 114.45,
          "maximum": 399.049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 279.3343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 14GAX15C",
      "code_information": [
        {
          "code": "5995547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 457,
          "minimum": 95.97,
          "maximum": 334.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 234.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 14GAX11C",
      "code_information": [
        {
          "code": "5995550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 416,
          "minimum": 87.36,
          "maximum": 304.5952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 213.2166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-H/S PROCEDURE     61-5205",
      "code_information": [
        {
          "code": "5995761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 584,
          "minimum": 122.64,
          "maximum": 427.6048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 299.3234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SERTERA-12GA CORE DEVICE",
      "code_information": [
        {
          "code": "5995763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SERTERA-14GA CORE DEVICE",
      "code_information": [
        {
          "code": "5995764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 428.4834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENCOR BX SCCAN01",
      "code_information": [
        {
          "code": "7295114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 79.4437,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC&RINSE TUBE DS4001",
      "code_information": [
        {
          "code": "7295115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 257.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-ENCOR NEEDLE 7G",
      "code_information": [
        {
          "code": "7295267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 69.7054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRI SCALPEL/NEEDLE KIT",
      "code_information": [
        {
          "code": "7295418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 159.9125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-HS TMI1156",
      "code_information": [
        {
          "code": "7295727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 50.7415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE F/MRI SSQK65/115VS",
      "code_information": [
        {
          "code": "7295730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 122.4971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-COAXIAL BIPSY 946x-VC-006",
      "code_information": [
        {
          "code": "1416380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OPTIFIX-ABSORBABLE 0113126",
      "code_information": [
        {
          "code": "3000012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 7.3     310.495",
      "code_information": [
        {
          "code": "3002265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT LARYNGEAL 4MM",
      "code_information": [
        {
          "code": "3003289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OXFORD SAW 506298",
      "code_information": [
        {
          "code": "3003294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-TUR PK           786500",
      "code_information": [
        {
          "code": "3003816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 96370-023",
      "code_information": [
        {
          "code": "3004233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-020",
      "code_information": [
        {
          "code": "3008516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 11X280       357.404",
      "code_information": [
        {
          "code": "3012311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX     2274-25-500",
      "code_information": [
        {
          "code": "3012384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 7.0X3.2",
      "code_information": [
        {
          "code": "3012900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-HALO CUTTING HACF-0533",
      "code_information": [
        {
          "code": "3013285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EVICEL FIBRIN SEALANT 3905",
      "code_information": [
        {
          "code": "3021100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-SEALER 5MM     LF1637",
      "code_information": [
        {
          "code": "3021738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-TUR       784415 & 784515",
      "code_information": [
        {
          "code": "3021867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3021877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NAVIGATED PAK9733498NAV",
      "code_information": [
        {
          "code": "3027426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-OPEN HEART     DYNJ32033A",
      "code_information": [
        {
          "code": "3029235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-ULTRASOUND ALL SZ 840-7s",
      "code_information": [
        {
          "code": "3034490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS EPIDUR VEIN",
      "code_information": [
        {
          "code": "3044898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DEEP SCROTAL RETRACTION",
      "code_information": [
        {
          "code": "3083072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS1",
      "code_information": [
        {
          "code": "3083596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-LIGASURE 37CM LF1944",
      "code_information": [
        {
          "code": "3559070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 16MM XFR004216",
      "code_information": [
        {
          "code": "3559091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-WIRELESS CELL EX1151",
      "code_information": [
        {
          "code": "3559233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-15MM/3.5OS 9159.3035",
      "code_information": [
        {
          "code": "3559597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 2.0",
      "code_information": [
        {
          "code": "3559670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3566817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40B GCS40B",
      "code_information": [
        {
          "code": "3598106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM 03.333.103",
      "code_information": [
        {
          "code": "3598147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-STRT TIP BAYON 1590-01",
      "code_information": [
        {
          "code": "3598218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH",
      "code_information": [
        {
          "code": "3598452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SUREFORM 60 480460",
      "code_information": [
        {
          "code": "3598611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 27CM APYX-27-TP",
      "code_information": [
        {
          "code": "3598956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-1X10.5MM BI 632.678S",
      "code_information": [
        {
          "code": "3599051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERCLAGE AR-7268",
      "code_information": [
        {
          "code": "3599170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-CERCLAGE AR-7268T",
      "code_information": [
        {
          "code": "3599171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM 03.333.102",
      "code_information": [
        {
          "code": "3599533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-NANO 125MM AR-3210-0043",
      "code_information": [
        {
          "code": "3600299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-MINI COREDX M00515220",
      "code_information": [
        {
          "code": "3600762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR CVD GCS40G",
      "code_information": [
        {
          "code": "3600838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-LARGE DV2012-LF",
      "code_information": [
        {
          "code": "3600953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-8-13MM P99-110-0813",
      "code_information": [
        {
          "code": "3601104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-UNIVERSAL PAD ARTICGEL",
      "code_information": [
        {
          "code": "3601634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIBER OPTIC PTEYE-1",
      "code_information": [
        {
          "code": "3602127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE 45\\\" HAR745",
      "code_information": [
        {
          "code": "3602909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE HAR736",
      "code_information": [
        {
          "code": "3602910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA 13CM PRE1101US",
      "code_information": [
        {
          "code": "3603187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 11G NN-1000",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 704.76,
          "maximum": 2457.2632,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 13G NN-1001",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY MAX M00546470",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL M00546550",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-RETRIEVAL M00546560",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-8MM/CV SF30 488530",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY 115CM G48240",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 25 LS96555-025",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SUPERLOOP TUR 784415",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-AO T8 93MM 542011",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-SD T20 93MM 542066",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BG 6MM ABS-8000-06",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-3 SYS REFERENCE   CREFP6",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X6MM 656306",
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        },
        {
          "code": "0270",
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        }
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X70MM 656370",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/178MM/RT 627490",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/173MM/RT 627338",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DEC BRIDGE 8H/RT 628068",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
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      "service_type": "CDM"
    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "outpatient",
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      ],
      "service_type": "CDM"
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    {
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        {
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      ],
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            {
              "payer_name": "Anthem",
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        }
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      "service_type": "CDM"
    },
    {
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        {
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        }
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1720.0842,
              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        },
        {
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        }
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            {
              "payer_name": "Anthem",
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              "count": "0",
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      "service_type": "CDM"
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        }
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              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAM SB3",
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        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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    },
    {
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        {
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      ],
      "standard_charges": [
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              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANTENNA-PROGRAMMER       37092",
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          "code": "3000651",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        310.111",
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          "code": "3002241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2       AR-8944-22",
      "code_information": [
        {
          "code": "3002251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0          316.396",
      "code_information": [
        {
          "code": "3002271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM         310.31",
      "code_information": [
        {
          "code": "3002300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM         310.11",
      "code_information": [
        {
          "code": "3002784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM         310.26",
      "code_information": [
        {
          "code": "3002788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM         310.44",
      "code_information": [
        {
          "code": "3002798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DISSECT ELECTRODE 139330",
      "code_information": [
        {
          "code": "3002955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW             511.9xxS",
      "code_information": [
        {
          "code": "3003266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS  03.000.3xxS",
      "code_information": [
        {
          "code": "3003268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 532.066S",
      "code_information": [
        {
          "code": "3003293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 225 ML04253",
      "code_information": [
        {
          "code": "3003420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 125ML 04251",
      "code_information": [
        {
          "code": "3003421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 4MM PAL-404LLB",
      "code_information": [
        {
          "code": "3004044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-304LLB",
      "code_information": [
        {
          "code": "3004046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO PAL-304LM",
      "code_information": [
        {
          "code": "3004053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPORT II PAL-406LS",
      "code_information": [
        {
          "code": "3004250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHOLANGIOGRAM       C100",
      "code_information": [
        {
          "code": "3005220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR TITANIUM  FV012T",
      "code_information": [
        {
          "code": "3009771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3          316.402",
      "code_information": [
        {
          "code": "3012305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM AR-4160-35",
      "code_information": [
        {
          "code": "3012347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.141",
      "code_information": [
        {
          "code": "3012354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 310.25",
      "code_information": [
        {
          "code": "3012405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-558",
      "code_information": [
        {
          "code": "3012475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 3.2X300MM",
      "code_information": [
        {
          "code": "3014238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUGE 03.804.5x",
      "code_information": [
        {
          "code": "3020805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PREP     546102000",
      "code_information": [
        {
          "code": "3020926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 24FR      880-213",
      "code_information": [
        {
          "code": "3021819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE WATER",
      "code_information": [
        {
          "code": "3023171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE  2839-xx-xxx",
      "code_information": [
        {
          "code": "3027302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTROSURG 134006",
      "code_information": [
        {
          "code": "3029511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-TRIMANO BEACH CHAIR",
      "code_information": [
        {
          "code": "3034325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL  1.5MM W/8.0MM STOP",
      "code_information": [
        {
          "code": "3058520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM CALIBRATED",
      "code_information": [
        {
          "code": "3058937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 19 G05880",
      "code_information": [
        {
          "code": "3058996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8943-",
      "code_information": [
        {
          "code": "3059000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-AIRWAY EXCH 8F G07833",
      "code_information": [
        {
          "code": "3059157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 11 G06732",
      "code_information": [
        {
          "code": "3059264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-4.5MM INCISOR PLUS",
      "code_information": [
        {
          "code": "3060481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 5MM          CB5LT",
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        {
          "code": "3079768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DOYLE II AIRWY 15-24055",
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        {
          "code": "3080045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-                TLC-55",
      "code_information": [
        {
          "code": "3081528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30GRN     TX30G",
      "code_information": [
        {
          "code": "3081555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30BL      TX30B",
      "code_information": [
        {
          "code": "3081557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-8916-14",
      "code_information": [
        {
          "code": "3087940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CALIBRATED DRILL 2.5",
      "code_information": [
        {
          "code": "3087942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER   60-6085-20x",
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        {
          "code": "3145100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER     G3640x",
      "code_information": [
        {
          "code": "3509540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3521005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BACK TABLE     DYNJ31777A",
      "code_information": [
        {
          "code": "3526152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-C-SECTION      DYNJ31780C",
      "code_information": [
        {
          "code": "3526153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VASCULAR LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3526426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSDUCER TRUWAVE PX272",
      "code_information": [
        {
          "code": "3526526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE UNTHREAD 2X200MM",
      "code_information": [
        {
          "code": "3526988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 16/18 FR 96551",
      "code_information": [
        {
          "code": "3527178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET",
      "code_information": [
        {
          "code": "3527263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SOMA ADULT SAFB-SM/USA",
      "code_information": [
        {
          "code": "3527866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DELIVERY NAVIFLEX 7FR.",
      "code_information": [
        {
          "code": "3527884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EPG CONNECTOR 53912D",
      "code_information": [
        {
          "code": "3549025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLOWSAFE II",
      "code_information": [
        {
          "code": "3549715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-NAIL 1806-1406S",
      "code_information": [
        {
          "code": "3549850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VORTRAN RESUSCITATION",
      "code_information": [
        {
          "code": "3550702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2020-00-335",
      "code_information": [
        {
          "code": "3550711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-DRILLING COMP EL-DTS",
      "code_information": [
        {
          "code": "3550764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SPEED FEMORAL AE-1605",
      "code_information": [
        {
          "code": "3550845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SELECTOR-VEIN 57538CSV-WOR",
      "code_information": [
        {
          "code": "3559121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-INSTRUMENT 0306-531-000",
      "code_information": [
        {
          "code": "3559266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-EXCELSIUS ARM 6143.2001S",
      "code_information": [
        {
          "code": "3559497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-MONITOR 6143.2003S",
      "code_information": [
        {
          "code": "3559498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-TRANSFUSION EXCHANGE",
      "code_information": [
        {
          "code": "3571501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR CARE XL MULTI-USE",
      "code_information": [
        {
          "code": "3598079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/KNEE WRAP",
      "code_information": [
        {
          "code": "3598180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/SHOULDER WRAP",
      "code_information": [
        {
          "code": "3598181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 94725",
      "code_information": [
        {
          "code": "3598197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE MIXTURE",
      "code_information": [
        {
          "code": "3598303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTYCORE 16GX7.5CM",
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        {
          "code": "3598364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELBOW TRIMANO AR-1646",
      "code_information": [
        {
          "code": "3598377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN 1.7/2.0 DRILL 45-20011",
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        {
          "code": "3598514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 10ML GIS-59",
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        {
          "code": "3599411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.1X150MM 03.333.001",
      "code_information": [
        {
          "code": "3599532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPAP BUBBLE MR290 CHAMBER",
      "code_information": [
        {
          "code": "3599616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.5X150MM QC 03.133.109",
      "code_information": [
        {
          "code": "3599727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-90° SAG 2296-003-109S2",
      "code_information": [
        {
          "code": "3599964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3600835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 16H 76-9103",
      "code_information": [
        {
          "code": "3600836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 24H 76-9104",
      "code_information": [
        {
          "code": "3600837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB NTHRD AR-18800-11",
      "code_information": [
        {
          "code": "3600896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE STER 03.804.519S",
      "code_information": [
        {
          "code": "3600903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G ACCESS 03.804.517S",
      "code_information": [
        {
          "code": "3600911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X330 S0100-000",
      "code_information": [
        {
          "code": "3601632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FISTULA FUNNEL",
      "code_information": [
        {
          "code": "3601648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE BVT 03.804.520S",
      "code_information": [
        {
          "code": "3601878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE RUNTHRU 180 25-5211",
      "code_information": [
        {
          "code": "3601952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE ARTERIAL ART356",
      "code_information": [
        {
          "code": "3602029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION PD-IT",
      "code_information": [
        {
          "code": "3602078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OIL-BIENAIR LUBRIFLUID 1600064",
      "code_information": [
        {
          "code": "3602105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE 16G X 16.5",
      "code_information": [
        {
          "code": "3602125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300S NTHRD 702463S",
      "code_information": [
        {
          "code": "3602409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL",
      "code_information": [
        {
          "code": "3602464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREDED AR-18800-11T",
      "code_information": [
        {
          "code": "3602495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-5 MREYE G36405",
      "code_information": [
        {
          "code": "3602688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-3 MREYE G42419",
      "code_information": [
        {
          "code": "3602689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3602820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G BVL 0306-331-000",
      "code_information": [
        {
          "code": "3603302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE -.9MM AR-7524C",
      "code_information": [
        {
          "code": "3604464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DBL 4X30/10 PAL-405LL",
      "code_information": [
        {
          "code": "3604617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-8x30/8 PAL-402LL",
      "code_information": [
        {
          "code": "3604619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GLIDESHEATH RM*ES6J10HAT",
      "code_information": [
        {
          "code": "3824107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X55MM 657055",
      "code_information": [
        {
          "code": "3900358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION RX  M00566670",
      "code_information": [
        {
          "code": "4822473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 458.7233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-VASCULAR 6MM X 7MM X 5FR",
      "code_information": [
        {
          "code": "1415480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-ANASTOCLIP LARGE 15CM",
      "code_information": [
        {
          "code": "3000773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-PASSER            8591-38",
      "code_information": [
        {
          "code": "3006601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE TISSUE REMOVAL",
      "code_information": [
        {
          "code": "3010310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED ASNIS III",
      "code_information": [
        {
          "code": "3012111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.5MM  702450",
      "code_information": [
        {
          "code": "3012114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST ASNIS III 6.5MM",
      "code_information": [
        {
          "code": "3012151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-HELI-FX            SG-64",
      "code_information": [
        {
          "code": "3016110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE EMG 8050015",
      "code_information": [
        {
          "code": "3022950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAK-CONFIDENCE PLUS",
      "code_information": [
        {
          "code": "3029292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARTHREX ANGEL BMC",
      "code_information": [
        {
          "code": "3058674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 8MMX24CM",
      "code_information": [
        {
          "code": "3058757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 6MMX17CM",
      "code_information": [
        {
          "code": "3058758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 4MMX7CM",
      "code_information": [
        {
          "code": "3058776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MM X xCM",
      "code_information": [
        {
          "code": "3058777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 6MM X xxCM",
      "code_information": [
        {
          "code": "3058840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 CX ALL",
      "code_information": [
        {
          "code": "3058847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MMX15CM",
      "code_information": [
        {
          "code": "3058884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-VERTEX DRILL 2.4MM",
      "code_information": [
        {
          "code": "3059197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-CAROTID ALL     2000-00s",
      "code_information": [
        {
          "code": "3079680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-INTERNAL EEA   EEAXL25",
      "code_information": [
        {
          "code": "3081425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-TVT DEVICE .5\\\"X18\\\" 810041",
      "code_information": [
        {
          "code": "3083229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EMBLEM TUNNELING 4711",
      "code_information": [
        {
          "code": "3084601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-PROGEL PGPS002",
      "code_information": [
        {
          "code": "3091508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER XPEEDA AC-1000729",
      "code_information": [
        {
          "code": "3526375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSSEPTAL NTK-711-8545",
      "code_information": [
        {
          "code": "3527245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 03.033.004",
      "code_information": [
        {
          "code": "3527874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-APEX 11CM 5500-25B-114",
      "code_information": [
        {
          "code": "3527983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-FEMORAL AUG SZ6 154906002",
      "code_information": [
        {
          "code": "3549097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-SPIN ACCESS INS-5900",
      "code_information": [
        {
          "code": "3550000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-INSERTER",
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        {
          "code": "3550237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-VASC 14X7MM SBT1402D",
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        {
          "code": "3550693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER ELEVATE 8340155",
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        {
          "code": "3559412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8013090",
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        {
          "code": "3559559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-9WX7L AR-8717-0907",
      "code_information": [
        {
          "code": "3598104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER SM 4934-8-100",
      "code_information": [
        {
          "code": "3600215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7FR 4",
      "code_information": [
        {
          "code": "3600789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7F 34",
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        {
          "code": "3600790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX 45MM 227445500",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PREP 4.2MM 0909-100-042",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EXP 4.2MM 0909-200-042",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-16 HLW 03.037.004S",
      "code_information": [
        {
          "code": "3601121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER MD 4934-8-140",
      "code_information": [
        {
          "code": "3601242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOCLOT EPK2303-01",
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        {
          "code": "3601392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AUX CBL PLT 94-1500-04-S",
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        {
          "code": "3601589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-DEBRIDEMENT DDBK02",
      "code_information": [
        {
          "code": "3601755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-GUIDE VDR 80-0049",
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          "code": "3602651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-DELIVERY STRBL-14F-075",
      "code_information": [
        {
          "code": "3603178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AO CONN P65-001-0001-SK",
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        {
          "code": "3603438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM RC P01-DWL-0915",
      "code_information": [
        {
          "code": "3604386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7.5FR",
      "code_information": [
        {
          "code": "3827764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBEROPTIC BALLOON 8.0FR",
      "code_information": [
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X34MM 657734",
      "code_information": [
        {
          "code": "3900153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 5641,
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X36MM 657736",
      "code_information": [
        {
          "code": "3900154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X38MM 657738",
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          "code": "3900155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.0X9MM 657709",
      "code_information": [
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          "code": "3900160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X11MM 656111",
      "code_information": [
        {
          "code": "3900161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.4X13MM 656113",
      "code_information": [
        {
          "code": "3900162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
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              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X26MM 663826",
      "code_information": [
        {
          "code": "3900208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/1.7MM 57-05202",
      "code_information": [
        {
          "code": "3900368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/LT 57-05221",
      "code_information": [
        {
          "code": "3900369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/RT 57-05220",
      "code_information": [
        {
          "code": "3900370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 6H/1.7MM 57-05240",
      "code_information": [
        {
          "code": "3900371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 10H/1.7 57-05262",
      "code_information": [
        {
          "code": "3900372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 7H/1.7MM 57-05260",
      "code_information": [
        {
          "code": "3900373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Y 7H/1.7MM 57-05270",
      "code_information": [
        {
          "code": "3900374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 5H/2.3MM 57-13405",
      "code_information": [
        {
          "code": "3900381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/2.3MM 57-13408",
      "code_information": [
        {
          "code": "3900382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 8H/2.3MM 57-13410",
      "code_information": [
        {
          "code": "3900383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-13421",
      "code_information": [
        {
          "code": "3900385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13440",
      "code_information": [
        {
          "code": "3900386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13450",
      "code_information": [
        {
          "code": "3900387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13906",
      "code_information": [
        {
          "code": "3900389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 2H/23MM 626672",
      "code_information": [
        {
          "code": "3900390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 3H/35MM",
      "code_information": [
        {
          "code": "3900391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 8.0MM LG AO",
      "code_information": [
        {
          "code": "3900392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/2.3 57-10190",
      "code_information": [
        {
          "code": "3900393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/RT 57-10120",
      "code_information": [
        {
          "code": "3900395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3MM 57-10140",
      "code_information": [
        {
          "code": "3900396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-SCREW F/ 2.7MM AO 703899",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2891.2381,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-SCREW F/ 3.5MM AO 703898",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 4H 629504",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 4H 629544",
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          "code": "3900403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "standard_charge_dollar": 2891.2381,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2+2H/1.7 57-05297",
      "code_information": [
        {
          "code": "3900406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "standard_charge_dollar": 2891.2381,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/1.7 57-052920",
      "code_information": [
        {
          "code": "3900407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7 57-05295",
      "code_information": [
        {
          "code": "3900410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/1.7/LT 57-05283",
      "code_information": [
        {
          "code": "3900411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/2.3MM 57-10402",
      "code_information": [
        {
          "code": "3900414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-10420",
      "code_information": [
        {
          "code": "3900417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10421",
      "code_information": [
        {
          "code": "3900418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10460",
      "code_information": [
        {
          "code": "3900420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP Y 6H/2.3MM 57-10470",
      "code_information": [
        {
          "code": "3900421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 2891.2381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-TOUHY BORST W/SIDE ARM",
      "code_information": [
        {
          "code": "1410050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-FEMORAL ANGIO  DYNJP4119",
      "code_information": [
        {
          "code": "1410800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18GX10CM   G01559",
      "code_information": [
        {
          "code": "1410916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-15      G03955",
      "code_information": [
        {
          "code": "1410919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CLOSED NEEDLE  LNGC-2022",
      "code_information": [
        {
          "code": "1495266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 9G EVIVA",
      "code_information": [
        {
          "code": "1495267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SWIVEL PORTEX 625191",
      "code_information": [
        {
          "code": "3002219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT ANT- 1012S",
      "code_information": [
        {
          "code": "3004017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-RANEY SCALP ADULT 20-1037",
      "code_information": [
        {
          "code": "3008833",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE       PMI-TC-SG",
      "code_information": [
        {
          "code": "3010072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE FUZZY       FZ624",
      "code_information": [
        {
          "code": "3020107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SURGISAFE ABSORB WHITE",
      "code_information": [
        {
          "code": "3029216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-UNIVRSL I AURO DYNJP1050A",
      "code_information": [
        {
          "code": "3029269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 10CM    70890856",
      "code_information": [
        {
          "code": "3029291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-STENT 6FR M0061802011",
      "code_information": [
        {
          "code": "3038668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR MANIFOLD",
      "code_information": [
        {
          "code": "3050023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 CX21D",
      "code_information": [
        {
          "code": "3058821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TRU               2C4041",
      "code_information": [
        {
          "code": "3079241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY METER ALL P4PxxULD",
      "code_information": [
        {
          "code": "3084872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COAG SUCTION      050-005",
      "code_information": [
        {
          "code": "3085551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ELECTROSURGICAL 8\\\"050-010",
      "code_information": [
        {
          "code": "3085595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX OUTFLOW AQL-111",
      "code_information": [
        {
          "code": "3086104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-3/8\\\"X3/32\\\"X8'     3508S",
      "code_information": [
        {
          "code": "3086137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8702H",
      "code_information": [
        {
          "code": "3089122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          JJ31G",
      "code_information": [
        {
          "code": "3089143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C016D",
      "code_information": [
        {
          "code": "3089188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 6-0          1732G",
      "code_information": [
        {
          "code": "3089203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX41",
      "code_information": [
        {
          "code": "3089216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J840D",
      "code_information": [
        {
          "code": "3089388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 CX22D",
      "code_information": [
        {
          "code": "3089700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-AERO          58-79510",
      "code_information": [
        {
          "code": "3284351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHARMBER-HEATER MR290",
      "code_information": [
        {
          "code": "3290069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ENDO TUBE ANCHORFAST",
      "code_information": [
        {
          "code": "3290137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ9 8.5CM",
      "code_information": [
        {
          "code": "3311077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PULLEY-OVERDOOR LUM101P",
      "code_information": [
        {
          "code": "3311351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADHESIVE-DERMABOND MINI",
      "code_information": [
        {
          "code": "3500037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SPIKE PRIMING   101593",
      "code_information": [
        {
          "code": "3500089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-HYPERINFLATION   1/2 LITER",
      "code_information": [
        {
          "code": "3501291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ADULT TALL LF/ALUM 7704",
      "code_information": [
        {
          "code": "3511782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHANNEL ALL JP22xx",
      "code_information": [
        {
          "code": "3512580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 F/PEDS PEDICAP6",
      "code_information": [
        {
          "code": "3512772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LTA MADGIC       MAD600",
      "code_information": [
        {
          "code": "3512793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL LRG     L-35MM",
      "code_information": [
        {
          "code": "3513122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3514273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEEDER-SPECIALNEEDS 80ML 6000S",
      "code_information": [
        {
          "code": "3515912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLD MIC 40M SQ40SK",
      "code_information": [
        {
          "code": "3516131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE ALL SZS     N7s",
      "code_information": [
        {
          "code": "3519400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-KNEE 22\\\"   1220917",
      "code_information": [
        {
          "code": "3519967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7089-0844",
      "code_information": [
        {
          "code": "3526221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 J864D",
      "code_information": [
        {
          "code": "3526246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 8X18",
      "code_information": [
        {
          "code": "3526255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP839D",
      "code_information": [
        {
          "code": "3526344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP838",
      "code_information": [
        {
          "code": "3526348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTOR-ADULT INTUBATED AIRWAY",
      "code_information": [
        {
          "code": "3526527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GROMMET-BEVELED VENT 70241350",
      "code_information": [
        {
          "code": "3527288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS INF-L",
      "code_information": [
        {
          "code": "3541326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS NEO-L",
      "code_information": [
        {
          "code": "3541327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DELIVER MORGAN LENS MT202",
      "code_information": [
        {
          "code": "3541942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD/IV FLUID WARMER L-70",
      "code_information": [
        {
          "code": "3542396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM PREMIE N4901",
      "code_information": [
        {
          "code": "3549181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 24 JP-2234",
      "code_information": [
        {
          "code": "3549296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOCKS-TISSUE FLT-010",
      "code_information": [
        {
          "code": "3549777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIRROR-INSPECTION DIABETIC 081",
      "code_information": [
        {
          "code": "3550157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM INFANT N4902",
      "code_information": [
        {
          "code": "3550255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVES-SKIL-CARE GERI SM 5669",
      "code_information": [
        {
          "code": "3550329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH MALE EXTERNAL MECSB01",
      "code_information": [
        {
          "code": "3550510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF LG MDS601LD",
      "code_information": [
        {
          "code": "3550554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE,MERSILINE 4-0 S-2 1779G",
      "code_information": [
        {
          "code": "3550847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT ANES 2L 72\\\"",
      "code_information": [
        {
          "code": "3559130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 S-14",
      "code_information": [
        {
          "code": "3559177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP774D",
      "code_information": [
        {
          "code": "3559182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-UNDER NOSE",
      "code_information": [
        {
          "code": "3559270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2350H",
      "code_information": [
        {
          "code": "3559280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 15 JP-2228",
      "code_information": [
        {
          "code": "3559392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 19 JP-2230",
      "code_information": [
        {
          "code": "3559393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-HUMIDIFER MR290V",
      "code_information": [
        {
          "code": "3559432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET NEO",
      "code_information": [
        {
          "code": "3559609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         C-017-D",
      "code_information": [
        {
          "code": "3560077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4258705",
      "code_information": [
        {
          "code": "3568756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-COBAN 2LAYER         2094",
      "code_information": [
        {
          "code": "3575850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND UNIVERSAL RT/LT LG",
      "code_information": [
        {
          "code": "3580012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIV 9006-00",
      "code_information": [
        {
          "code": "3580022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3598026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MAC",
      "code_information": [
        {
          "code": "3598027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LAPAROSCOPIC STR 2190J",
      "code_information": [
        {
          "code": "3598116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-POLY OVAL SOFT WIRE",
      "code_information": [
        {
          "code": "3598262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ARTHROGRAM DYNJ07425",
      "code_information": [
        {
          "code": "3598354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 1 VCP741D",
      "code_information": [
        {
          "code": "3598416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NERVE BLOCK 22G HN3S-80",
      "code_information": [
        {
          "code": "3598440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAG-DISP SUCT 10’ 30-5201",
      "code_information": [
        {
          "code": "3598648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1 VASC1346",
      "code_information": [
        {
          "code": "3598865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/63-74\\\" 1146PP",
      "code_information": [
        {
          "code": "3598976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-NASAL VIP1137380",
      "code_information": [
        {
          "code": "3599139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-NASAL VIP1137381",
      "code_information": [
        {
          "code": "3599142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE RENOVARP GIS-29",
      "code_information": [
        {
          "code": "3599229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 17-22CM",
      "code_information": [
        {
          "code": "3599603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 22-25CM",
      "code_information": [
        {
          "code": "3599604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 25-29CM",
      "code_information": [
        {
          "code": "3599605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 29-36CM",
      "code_information": [
        {
          "code": "3599606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 240014",
      "code_information": [
        {
          "code": "3599773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SSL",
      "code_information": [
        {
          "code": "3600225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1MSL",
      "code_information": [
        {
          "code": "3600226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1LSL",
      "code_information": [
        {
          "code": "3600227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL WIDE EVO1WSL",
      "code_information": [
        {
          "code": "3600228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2SSL",
      "code_information": [
        {
          "code": "3600230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2MSL",
      "code_information": [
        {
          "code": "3600231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2LSL",
      "code_information": [
        {
          "code": "3600232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CN 10MM HEX P45-940-0001",
      "code_information": [
        {
          "code": "3600608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-JTIP .025X33CM",
      "code_information": [
        {
          "code": "3600780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP726D",
      "code_information": [
        {
          "code": "3601389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SEDLINE RD",
      "code_information": [
        {
          "code": "3601706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMP SENSING 16FR 119216",
      "code_information": [
        {
          "code": "3601726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PREM CS006",
      "code_information": [
        {
          "code": "3601999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 0 VCPP31D",
      "code_information": [
        {
          "code": "3602463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-INSTRUMENT T50106",
      "code_information": [
        {
          "code": "3603056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63447",
      "code_information": [
        {
          "code": "3603065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63446",
      "code_information": [
        {
          "code": "3603066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63445",
      "code_information": [
        {
          "code": "3603067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE PMITCSG",
      "code_information": [
        {
          "code": "3603191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3603332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-BIOPSY ORT 27550ZAG/10",
      "code_information": [
        {
          "code": "3603541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG GOLD NR30001010",
      "code_information": [
        {
          "code": "3603912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NOMOLINE LH AIRWAY ADAPTER",
      "code_information": [
        {
          "code": "3603959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED W/ PEEP VALVE",
      "code_information": [
        {
          "code": "3603963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADULT W/ PEEP VAL",
      "code_information": [
        {
          "code": "3603964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION C2202",
      "code_information": [
        {
          "code": "3603996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP840D",
      "code_information": [
        {
          "code": "3604214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROVOX-DILATOR 8341",
      "code_information": [
        {
          "code": "3604745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PERFUSION PUMP 6320",
      "code_information": [
        {
          "code": "3604835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION 120MM",
      "code_information": [
        {
          "code": "3604953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-TRANSDUCER     K11-00096",
      "code_information": [
        {
          "code": "3820165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMPSENSING 16FR   117416",
      "code_information": [
        {
          "code": "3822997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL 4FR 20CM G02366",
      "code_information": [
        {
          "code": "3823450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY          000109",
      "code_information": [
        {
          "code": "4820900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION 16G",
      "code_information": [
        {
          "code": "4825435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 91.7447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 J305H",
      "code_information": [
        {
          "code": "3012910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL3-0 27\\\" FS-2",
      "code_information": [
        {
          "code": "3033304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-ETHICON         PCP-20",
      "code_information": [
        {
          "code": "3033960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUT-PDS 2-0 Z317H",
      "code_information": [
        {
          "code": "3059073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VIC 2-0           J317H",
      "code_information": [
        {
          "code": "3088957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J329H",
      "code_information": [
        {
          "code": "3088960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y215H",
      "code_information": [
        {
          "code": "3088973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y214H",
      "code_information": [
        {
          "code": "3088974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-RETENTION 450G",
      "code_information": [
        {
          "code": "3088984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 36\\\"        Z346H",
      "code_information": [
        {
          "code": "3088987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y398H",
      "code_information": [
        {
          "code": "3088989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J602H",
      "code_information": [
        {
          "code": "3088995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y346H",
      "code_information": [
        {
          "code": "3088999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL  0         J946G",
      "code_information": [
        {
          "code": "3089001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J603H",
      "code_information": [
        {
          "code": "3089003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J270H",
      "code_information": [
        {
          "code": "3089004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J341H",
      "code_information": [
        {
          "code": "3089009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J338H",
      "code_information": [
        {
          "code": "3089016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J311H",
      "code_information": [
        {
          "code": "3089021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRL 1        Y341H",
      "code_information": [
        {
          "code": "3089036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y340H",
      "code_information": [
        {
          "code": "3089037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8425H",
      "code_information": [
        {
          "code": "3089050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8424H",
      "code_information": [
        {
          "code": "3089052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8412H",
      "code_information": [
        {
          "code": "3089053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8433H",
      "code_information": [
        {
          "code": "3089062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8417H",
      "code_information": [
        {
          "code": "3089070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J633H",
      "code_information": [
        {
          "code": "3089091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0          802H",
      "code_information": [
        {
          "code": "3089130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1         S115H",
      "code_information": [
        {
          "code": "3089137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1          865H",
      "code_information": [
        {
          "code": "3089138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1          813H",
      "code_information": [
        {
          "code": "3089139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J370H",
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        {
          "code": "3089144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 1       S105H",
      "code_information": [
        {
          "code": "3089149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            K835H",
      "code_information": [
        {
          "code": "3089164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            SA86G",
      "code_information": [
        {
          "code": "3089165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0      852H",
      "code_information": [
        {
          "code": "3089167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     H821H",
      "code_information": [
        {
          "code": "3089171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            A186H",
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        {
          "code": "3089173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           623H",
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        {
          "code": "3089176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A184H",
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        {
          "code": "3089178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3089183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A305H",
      "code_information": [
        {
          "code": "3089185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A185H",
      "code_information": [
        {
          "code": "3089186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K831H",
      "code_information": [
        {
          "code": "3089193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0           684H",
      "code_information": [
        {
          "code": "3089198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          A183H",
      "code_information": [
        {
          "code": "3089200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        636H",
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        {
          "code": "3089205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X964H",
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        {
          "code": "3089208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2        X519H",
      "code_information": [
        {
          "code": "3089213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X518H",
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        {
          "code": "3089214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0       1674H",
      "code_information": [
        {
          "code": "3089236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1673H",
      "code_information": [
        {
          "code": "3089242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        627H",
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        {
          "code": "3089245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z339H",
      "code_information": [
        {
          "code": "3089255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0   Z304H",
      "code_information": [
        {
          "code": "3089260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J442H",
      "code_information": [
        {
          "code": "3089274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 1689H",
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        {
          "code": "3089276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            SA87G",
      "code_information": [
        {
          "code": "3089277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2          J880T",
      "code_information": [
        {
          "code": "3089278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2          460T",
      "code_information": [
        {
          "code": "3089298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J214H",
      "code_information": [
        {
          "code": "3089329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J662H",
      "code_information": [
        {
          "code": "3089339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J347H",
      "code_information": [
        {
          "code": "3089347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J335H",
      "code_information": [
        {
          "code": "3089359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X425H",
      "code_information": [
        {
          "code": "3089385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z333H",
      "code_information": [
        {
          "code": "3089395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 626H",
      "code_information": [
        {
          "code": "3089409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685H",
      "code_information": [
        {
          "code": "3500610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    684G",
      "code_information": [
        {
          "code": "3500770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          K872H",
      "code_information": [
        {
          "code": "3501015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 18FR 30CC      266718",
      "code_information": [
        {
          "code": "3507735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 0 PDP340H",
      "code_information": [
        {
          "code": "3526247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-3-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-3-0 PLUS",
      "code_information": [
        {
          "code": "3526254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 1 PDP341H",
      "code_information": [
        {
          "code": "3549733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 4-0 R633H",
      "code_information": [
        {
          "code": "3549987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        635G",
      "code_information": [
        {
          "code": "3555389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           622-H",
      "code_information": [
        {
          "code": "3557329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK O             624H",
      "code_information": [
        {
          "code": "3557386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            K834H",
      "code_information": [
        {
          "code": "3557388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           661-G",
      "code_information": [
        {
          "code": "3557535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           662-G",
      "code_information": [
        {
          "code": "3557568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           663-H",
      "code_information": [
        {
          "code": "3557592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 2.0        664G",
      "code_information": [
        {
          "code": "3557990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON            801H",
      "code_information": [
        {
          "code": "3558467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 3-0        1671-H",
      "code_information": [
        {
          "code": "3559001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         B-842-H",
      "code_information": [
        {
          "code": "3560064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH CHROMIC 3-0 G-122-H",
      "code_information": [
        {
          "code": "3560211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J219H",
      "code_information": [
        {
          "code": "3560487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J258H",
      "code_information": [
        {
          "code": "3560490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-259-H",
      "code_information": [
        {
          "code": "3560505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL          J-416-H",
      "code_information": [
        {
          "code": "3560745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J415H",
      "code_information": [
        {
          "code": "3560840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J417H",
      "code_information": [
        {
          "code": "3561410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        669H",
      "code_information": [
        {
          "code": "3561418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 3-0  J-944-H",
      "code_information": [
        {
          "code": "3561419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-832-H",
      "code_information": [
        {
          "code": "3561461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-833-H",
      "code_information": [
        {
          "code": "3561495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH MONOCRL 2-0   Y259H",
      "code_information": [
        {
          "code": "3562109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3.0    Y-338-H",
      "code_information": [
        {
          "code": "3562123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y416H",
      "code_information": [
        {
          "code": "3562126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0     H822H",
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        {
          "code": "3562128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 FS-1    1629H",
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        {
          "code": "3562140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8683G",
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        {
          "code": "3562227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           683G",
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        {
          "code": "3562240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "gross_charge": 14,
          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K871H",
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        {
          "code": "3562245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP316H",
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        {
          "code": "3598241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP945G",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-VICRYL 4-0 J422H",
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        {
          "code": "3598401",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL SZ 1 36\\\" J519H",
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        {
          "code": "3598406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS #1 VCP371H",
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        {
          "code": "3598411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 G181H",
      "code_information": [
        {
          "code": "3598414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 2.94,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1670H",
      "code_information": [
        {
          "code": "3598421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 2-0 VCP195H",
      "code_information": [
        {
          "code": "3598422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ #1 VCP569H",
      "code_information": [
        {
          "code": "3598423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 4.0 VCP310H",
      "code_information": [
        {
          "code": "3598433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0 664H",
      "code_information": [
        {
          "code": "3598435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 J306H",
      "code_information": [
        {
          "code": "3598715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP311H",
      "code_information": [
        {
          "code": "3602123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 663G",
      "code_information": [
        {
          "code": "3602506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 2-0 MCP345H",
      "code_information": [
        {
          "code": "3602920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0   Y303H",
      "code_information": [
        {
          "code": "3603113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 VCP602H",
      "code_information": [
        {
          "code": "3603514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP305H",
      "code_information": [
        {
          "code": "3604136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP422H",
      "code_information": [
        {
          "code": "3604226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP218H",
      "code_information": [
        {
          "code": "3604353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 4-0 VCP434H",
      "code_information": [
        {
          "code": "3604548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP603H",
      "code_information": [
        {
          "code": "3604710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP946H",
      "code_information": [
        {
          "code": "3604711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BLK 3-0 18\\\"\\\" 642G",
      "code_information": [
        {
          "code": "3604940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        X424H",
      "code_information": [
        {
          "code": "3824629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J269H",
      "code_information": [
        {
          "code": "3824633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J232H",
      "code_information": [
        {
          "code": "3824634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J434H",
      "code_information": [
        {
          "code": "3824636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 30\\\"    X444H",
      "code_information": [
        {
          "code": "3824647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 27\\\"    J443H",
      "code_information": [
        {
          "code": "3824648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X411",
      "code_information": [
        {
          "code": "3824706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 7.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 7FR       06-107F",
      "code_information": [
        {
          "code": "1415875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 MS-DC5020",
      "code_information": [
        {
          "code": "3002250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          MS-DC28",
      "code_information": [
        {
          "code": "3002372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DERMATOME 00-8800-000-10",
      "code_information": [
        {
          "code": "3002650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-7.3 ARCH AORTIC MT022A",
      "code_information": [
        {
          "code": "3004031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHOULDER ALL AR-6500s",
      "code_information": [
        {
          "code": "3004216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS HIFLO 24F 69324",
      "code_information": [
        {
          "code": "3004482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR        12002",
      "code_information": [
        {
          "code": "3004521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-5MM PROT BLUE 5027-1050",
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        {
          "code": "3004650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-34 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-42 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009960",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-UTERINE MANIPULATOR",
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        {
          "code": "3019600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT         PI-104",
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        {
          "code": "3019880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MAGNUM BIOPSY    MN18xx",
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        {
          "code": "3027515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-CANNULA XI      470381",
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        {
          "code": "3039883",
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        {
          "code": "0270",
          "type": "RC"
        }
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-SUTURE ASSISTANT  SW110",
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          "code": "0270",
          "type": "RC"
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETAINER-VISCERA LARGE HS-3206",
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        {
          "code": "3040486",
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        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-5-0 BV-1 BLUE EPH9702H",
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          "code": "3058802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 2xFR",
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          "code": "3058922",
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL NEW",
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          "code": "3059210",
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN",
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        {
          "code": "3059265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-VIA-GUARD SMP-2006-001",
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        {
          "code": "3060015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 16\\\" 7716-000-10",
      "code_information": [
        {
          "code": "3060133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THREADED 72200425",
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        {
          "code": "3060484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-ELECTROLUBE         EL101",
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        {
          "code": "3078867",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING           031229-10",
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        {
          "code": "3079239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNELER 16G     ACC10S",
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        {
          "code": "3079464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SEPTAL NEIMAN  14-0441",
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        {
          "code": "3080203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMDxx40x",
      "code_information": [
        {
          "code": "3082490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-EYE 10.0          7711G",
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        {
          "code": "3082557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-IRRIG SUCT 250070530",
      "code_information": [
        {
          "code": "3083086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 45CM     3909",
      "code_information": [
        {
          "code": "3083636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-ONQ ALL         T1X's",
      "code_information": [
        {
          "code": "3086215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS ADAPTER",
      "code_information": [
        {
          "code": "3087517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 1010030",
      "code_information": [
        {
          "code": "3088591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 5        RS21",
      "code_information": [
        {
          "code": "3089261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-BLUE VLOCN0615",
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        {
          "code": "3089401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXMP1B117",
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        {
          "code": "3089421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 3.2MM        702462",
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        {
          "code": "3091254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             1101",
      "code_information": [
        {
          "code": "3093210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS 420023",
      "code_information": [
        {
          "code": "3155010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS LONG",
      "code_information": [
        {
          "code": "3155020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION ADJ",
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        {
          "code": "3311604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
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              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBIGRIP D 1437",
      "code_information": [
        {
          "code": "3503055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD           KVL03",
      "code_information": [
        {
          "code": "3504920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH X3-003-000",
      "code_information": [
        {
          "code": "3504921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 1L    622283",
      "code_information": [
        {
          "code": "3505720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 600ML 622278",
      "code_information": [
        {
          "code": "3505722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC FREEDOM 300ML",
      "code_information": [
        {
          "code": "3506124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CRITICORE URINARY  900216",
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        {
          "code": "3506760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC ALL SZ",
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        {
          "code": "3510098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYLOG 3000 DISPOSABLE",
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        {
          "code": "3510130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COLLECTN BREAST MILK  67's",
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        {
          "code": "3521700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE A ARTERIAL    400115A",
      "code_information": [
        {
          "code": "3521984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-KIWI OMNI SYSTEM",
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        {
          "code": "3522453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22G X 20CM",
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          "code": "3526117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PULSAVAC IRRIGATION",
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        {
          "code": "3526128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-KENNEDY SINUS      400426",
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        {
          "code": "3526168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 30 SXPP1B410",
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        {
          "code": "3526382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 34 DPSB 60707010600",
      "code_information": [
        {
          "code": "3526496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMD2B401",
      "code_information": [
        {
          "code": "3526937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-HEEL SUSPENSION   M60-300",
      "code_information": [
        {
          "code": "3528097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 42 DPSB 60707010700",
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        {
          "code": "3529497",
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "SENSORMAT-CHAIR-CHEC 65815-030",
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        {
          "code": "3541322",
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
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      "service_type": "CDM"
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    {
      "description": "SET-CATH HSG 5FR TMI      1154",
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        {
          "code": "3541914",
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        {
          "code": "0270",
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        {
          "setting": "outpatient",
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "CANNULA-ZONE NAVIGATOR AR790x",
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        {
          "code": "3547988",
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        {
          "code": "0270",
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        {
          "setting": "outpatient",
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "WIRE-K OLIVE 2MM 703818",
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          "code": "3549171",
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        {
          "code": "0270",
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      ],
      "service_type": "CDM"
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    {
      "description": "BLADE-SAW SAGITTAL 40X14X0.6",
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        {
          "code": "3549447",
          "type": "LOCAL"
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        {
          "code": "0270",
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      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
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    {
      "description": "BURR-DIAMOND 5MM 0227-010-250",
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          "code": "3549930",
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        {
          "code": "0270",
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-INTRACK ULTRA 66MM",
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        {
          "code": "3550346",
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        {
          "code": "0270",
          "type": "RC"
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "TRAY-CATH TEMP SENSING 18FR A3",
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          "code": "3550415",
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        {
          "code": "0270",
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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    {
      "description": "VALVE-C1/T1/MR1 EXPIRATORY 161",
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        {
          "code": "0270",
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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    },
    {
      "description": "CIRCUIT-COAXIAL BREATHING DISP",
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        {
          "code": "0270",
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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      "service_type": "CDM"
    },
    {
      "description": "GLOVE-WHEELCHAIR MEDIUM 565613",
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        {
          "code": "0270",
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        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "CATH-FOLEY 2/W COUDE",
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
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    {
      "description": "WIRE-K 1.25X200MM A-5040.30/1",
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        {
          "code": "0270",
          "type": "RC"
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
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    },
    {
      "description": "KIT-DELUXE KNEE/HIP 081603273",
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        {
          "code": "3550839",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
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    {
      "description": "SET-INTERPULSE HANDLE W TIP",
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        {
          "code": "0270",
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
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    {
      "description": "TROCAR-W/CANNULA 12MM ONB12STF",
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        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION A495LM",
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        {
          "code": "0270",
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      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
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      "description": "MASK-AF541",
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        {
          "code": "0270",
          "type": "RC"
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ4",
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          "code": "3559252",
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        },
        {
          "code": "0270",
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      ],
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        {
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URI-CATH 3.5FR&5.0FR",
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        {
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              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PROCEDURE PICC W/O PICC",
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        },
        {
          "code": "0270",
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      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        },
        {
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          "type": "RC"
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      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF 7.0MM",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 18GA    9001C0212",
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        {
          "code": "3590035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 8.0MM",
      "code_information": [
        {
          "code": "3590138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-POLAR KNEE WRAP-ON",
      "code_information": [
        {
          "code": "3598080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMP2B401",
      "code_information": [
        {
          "code": "3598157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER PAD F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH 5FR TMI1185",
      "code_information": [
        {
          "code": "3598221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSPAC TRIFURCATED 42800",
      "code_information": [
        {
          "code": "3598244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BONE MARROW 11GX4\\\" BAK451",
      "code_information": [
        {
          "code": "3598402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM BLADED CTB73",
      "code_information": [
        {
          "code": "3598438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4X70/16MM 607470",
      "code_information": [
        {
          "code": "3598460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 GORE-TEX 4N10B",
      "code_information": [
        {
          "code": "3598958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 18 FR",
      "code_information": [
        {
          "code": "3599116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 16 FR",
      "code_information": [
        {
          "code": "3599117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-NITINOL PILOT 5901-6072",
      "code_information": [
        {
          "code": "3599187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/25CM MN1825",
      "code_information": [
        {
          "code": "3599317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSIONS-CABLE DISP 4051L",
      "code_information": [
        {
          "code": "3599647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.1CM",
      "code_information": [
        {
          "code": "3600164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL EVF1XMLSLA",
      "code_information": [
        {
          "code": "3600224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.6X150MM P99-292-1615",
      "code_information": [
        {
          "code": "3600326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-CAPTURA DISP G53006",
      "code_information": [
        {
          "code": "3600504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-192-2330",
      "code_information": [
        {
          "code": "3600521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TENNIS RACQUET 5FR/90CM",
      "code_information": [
        {
          "code": "3600554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ 3",
      "code_information": [
        {
          "code": "3600778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-2.0X200MM P99-192-2020",
      "code_information": [
        {
          "code": "3601106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,GASTRO MIC",
      "code_information": [
        {
          "code": "3601451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MIAR 14G 7FR 11014L",
      "code_information": [
        {
          "code": "3601478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-OSIA OSI200 P1291019",
      "code_information": [
        {
          "code": "3601610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300 NTHRD 702463",
      "code_information": [
        {
          "code": "3601870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-193-2323",
      "code_information": [
        {
          "code": "3602140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.1MM AR-8655K-11",
      "code_information": [
        {
          "code": "3602154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SHEATH W/CATH SA-09847",
      "code_information": [
        {
          "code": "3602436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PT PUMP 8\\\"\\\" AR-6421",
      "code_information": [
        {
          "code": "3602461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-RING 16\\\" DUR8016W",
      "code_information": [
        {
          "code": "3602526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.2X150 TH P99-193-1215",
      "code_information": [
        {
          "code": "3602570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP TRB29-LRG",
      "code_information": [
        {
          "code": "3602758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.0X200MM P99-193-2020",
      "code_information": [
        {
          "code": "3602993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X100MM P99-192-1410",
      "code_information": [
        {
          "code": "3603370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-BIVENTRICULAR BS-101-97",
      "code_information": [
        {
          "code": "3603546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 3-0 PS-2",
      "code_information": [
        {
          "code": "3603921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.4X15 MSG14150",
      "code_information": [
        {
          "code": "3604046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.6X15 MSG16150",
      "code_information": [
        {
          "code": "3604056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X150MM P99-292-0915",
      "code_information": [
        {
          "code": "3604177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X150 SM P99-192-2315",
      "code_information": [
        {
          "code": "3604181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-292-1115",
      "code_information": [
        {
          "code": "3604182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1615",
      "code_information": [
        {
          "code": "3604183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1415",
      "code_information": [
        {
          "code": "3604184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-U-FRAME STRD MT-APU-2.4",
      "code_information": [
        {
          "code": "3604229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADS-LACURA VISCO FOOT",
      "code_information": [
        {
          "code": "3604310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-HEX 10MM 76-10185",
      "code_information": [
        {
          "code": "3604312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-GUARDIAN HEMOSTAT 8215",
      "code_information": [
        {
          "code": "3604336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-WASTE 04369",
      "code_information": [
        {
          "code": "3604367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K .9X150MM P99-192-0915",
      "code_information": [
        {
          "code": "3604377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG 900-152",
      "code_information": [
        {
          "code": "3604585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD-EX 900-154",
      "code_information": [
        {
          "code": "3604586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD 900-151",
      "code_information": [
        {
          "code": "3604587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG-SHL 900-155",
      "code_information": [
        {
          "code": "3604588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Pathway Transitions HMO",
              "standard_charge_dollar": 191.1774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 7FR       06-107F",
      "code_information": [
        {
          "code": "1415875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 MS-DC5020",
      "code_information": [
        {
          "code": "3002250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          MS-DC28",
      "code_information": [
        {
          "code": "3002372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DERMATOME 00-8800-000-10",
      "code_information": [
        {
          "code": "3002650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-7.3 ARCH AORTIC MT022A",
      "code_information": [
        {
          "code": "3004031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHOULDER ALL AR-6500s",
      "code_information": [
        {
          "code": "3004216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS HIFLO 24F 69324",
      "code_information": [
        {
          "code": "3004482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR        12002",
      "code_information": [
        {
          "code": "3004521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-5MM PROT BLUE 5027-1050",
      "code_information": [
        {
          "code": "3004650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
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              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-34 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-42 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER TOP 44X44 ORS-100",
      "code_information": [
        {
          "code": "3011925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT         PI-104",
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        {
          "code": "3019880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MAGNUM BIOPSY    MN18xx",
      "code_information": [
        {
          "code": "3027515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-PERI-OB DRAPE       2997",
      "code_information": [
        {
          "code": "3034345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-CANNULA XI      470381",
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        {
          "code": "3039883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-SUTURE ASSISTANT  SW110",
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        {
          "code": "3039900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETAINER-VISCERA LARGE HS-3206",
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        {
          "code": "3040486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 BV-1 BLUE EPH9702H",
      "code_information": [
        {
          "code": "3058802",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 2xFR",
      "code_information": [
        {
          "code": "3058922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL NEW",
      "code_information": [
        {
          "code": "3059210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN",
      "code_information": [
        {
          "code": "3059265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-VIA-GUARD SMP-2006-001",
      "code_information": [
        {
          "code": "3060015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 16\\\" 7716-000-10",
      "code_information": [
        {
          "code": "3060133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-ELECTROLUBE         EL101",
      "code_information": [
        {
          "code": "3078867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING           031229-10",
      "code_information": [
        {
          "code": "3079239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNELER 16G     ACC10S",
      "code_information": [
        {
          "code": "3079464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SEPTAL NEIMAN  14-0441",
      "code_information": [
        {
          "code": "3080203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMDxx40x",
      "code_information": [
        {
          "code": "3082490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-EYE 10.0          7711G",
      "code_information": [
        {
          "code": "3082557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-IRRIG SUCT 250070530",
      "code_information": [
        {
          "code": "3083086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 45CM     3909",
      "code_information": [
        {
          "code": "3083636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-ONQ ALL         T1X's",
      "code_information": [
        {
          "code": "3086215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS ADAPTER",
      "code_information": [
        {
          "code": "3087517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 1010030",
      "code_information": [
        {
          "code": "3088591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 5        RS21",
      "code_information": [
        {
          "code": "3089261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-BLUE VLOCN0615",
      "code_information": [
        {
          "code": "3089401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 3.2MM        702462",
      "code_information": [
        {
          "code": "3091254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             1101",
      "code_information": [
        {
          "code": "3093210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS 420023",
      "code_information": [
        {
          "code": "3155010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM BLADELESS LONG",
      "code_information": [
        {
          "code": "3155020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION ADJ",
      "code_information": [
        {
          "code": "3311604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBIGRIP D 1437",
      "code_information": [
        {
          "code": "3503055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD           KVL03",
      "code_information": [
        {
          "code": "3504920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH X3-003-000",
      "code_information": [
        {
          "code": "3504921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-EVAC/DRAIN 600ML 622278",
      "code_information": [
        {
          "code": "3505722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-VAC FREEDOM 300ML",
      "code_information": [
        {
          "code": "3506124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CRITICORE URINARY  900216",
      "code_information": [
        {
          "code": "3506760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC ALL SZ",
      "code_information": [
        {
          "code": "3510098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COLLECTN BREAST MILK  67's",
      "code_information": [
        {
          "code": "3521700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE A ARTERIAL    400115A",
      "code_information": [
        {
          "code": "3521984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-KIWI OMNI SYSTEM",
      "code_information": [
        {
          "code": "3522453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22G X 20CM",
      "code_information": [
        {
          "code": "3526117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PULSAVAC IRRIGATION",
      "code_information": [
        {
          "code": "3526128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-KENNEDY SINUS      400426",
      "code_information": [
        {
          "code": "3526168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 30 SXPP1B410",
      "code_information": [
        {
          "code": "3526382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 34 DPSB 60707010600",
      "code_information": [
        {
          "code": "3526496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMD2B401",
      "code_information": [
        {
          "code": "3526937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-HEEL SUSPENSION   M60-300",
      "code_information": [
        {
          "code": "3528097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 42 DPSB 60707010700",
      "code_information": [
        {
          "code": "3529497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSORMAT-CHAIR-CHEC 65815-030",
      "code_information": [
        {
          "code": "3541322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH HSG 5FR TMI      1154",
      "code_information": [
        {
          "code": "3541914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ZONE NAVIGATOR AR790x",
      "code_information": [
        {
          "code": "3547988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K OLIVE 2MM 703818",
      "code_information": [
        {
          "code": "3549171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAGITTAL 40X14X0.6",
      "code_information": [
        {
          "code": "3549447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 5MM 0227-010-250",
      "code_information": [
        {
          "code": "3549930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-INTRACK ULTRA 66MM",
      "code_information": [
        {
          "code": "3550346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR A3",
      "code_information": [
        {
          "code": "3550415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-C1/T1/MR1 EXPIRATORY 161",
      "code_information": [
        {
          "code": "3550566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-COAXIAL BREATHING DISP",
      "code_information": [
        {
          "code": "3550567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-WHEELCHAIR MEDIUM 565613",
      "code_information": [
        {
          "code": "3550733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.25X200MM A-5040.30/1",
      "code_information": [
        {
          "code": "3550826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DELUXE KNEE/HIP 081603273",
      "code_information": [
        {
          "code": "3550839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INTERPULSE HANDLE W TIP",
      "code_information": [
        {
          "code": "3550870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 12MM ONB12STF",
      "code_information": [
        {
          "code": "3559126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ULNAR DEVIATION A495LM",
      "code_information": [
        {
          "code": "3559184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ4",
      "code_information": [
        {
          "code": "3559252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PROCEDURE PICC W/O PICC",
      "code_information": [
        {
          "code": "3570790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 8.0MM",
      "code_information": [
        {
          "code": "3573913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF 7.0MM",
      "code_information": [
        {
          "code": "3573939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 18GA    9001C0212",
      "code_information": [
        {
          "code": "3590035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 8.0MM",
      "code_information": [
        {
          "code": "3590138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-POLAR KNEE WRAP-ON",
      "code_information": [
        {
          "code": "3598080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 2-0 SXMP2B401",
      "code_information": [
        {
          "code": "3598157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER PAD F/POLAR CUBE",
      "code_information": [
        {
          "code": "3598183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH 5FR TMI1185",
      "code_information": [
        {
          "code": "3598221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSPAC TRIFURCATED 42800",
      "code_information": [
        {
          "code": "3598244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BONE MARROW 11GX4\\\" BAK451",
      "code_information": [
        {
          "code": "3598402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM BLADED CTB73",
      "code_information": [
        {
          "code": "3598438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 4X70/16MM 607470",
      "code_information": [
        {
          "code": "3598460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 GORE-TEX 4N10B",
      "code_information": [
        {
          "code": "3598958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 18 FR",
      "code_information": [
        {
          "code": "3599116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 3 PORT 16 FR",
      "code_information": [
        {
          "code": "3599117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-NITINOL PILOT 5901-6072",
      "code_information": [
        {
          "code": "3599187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/25CM MN1825",
      "code_information": [
        {
          "code": "3599317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSIONS-CABLE DISP 4051L",
      "code_information": [
        {
          "code": "3599647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.1CM",
      "code_information": [
        {
          "code": "3600164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL EVF1XMLSLA",
      "code_information": [
        {
          "code": "3600224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.6X150MM P99-292-1615",
      "code_information": [
        {
          "code": "3600326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-CAPTURA DISP G53006",
      "code_information": [
        {
          "code": "3600504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-192-2330",
      "code_information": [
        {
          "code": "3600521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TENNIS RACQUET 5FR/90CM",
      "code_information": [
        {
          "code": "3600554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AIRWAY SUPRAGLOTTIC SZ 3",
      "code_information": [
        {
          "code": "3600778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-2.0X200MM P99-192-2020",
      "code_information": [
        {
          "code": "3601106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MIAR 14G 7FR 11014L",
      "code_information": [
        {
          "code": "3601478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-OSIA OSI200 P1291019",
      "code_information": [
        {
          "code": "3601610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300 NTHRD 702463",
      "code_information": [
        {
          "code": "3601870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X230MM P99-193-2323",
      "code_information": [
        {
          "code": "3602140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.1MM AR-8655K-11",
      "code_information": [
        {
          "code": "3602154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SHEATH W/CATH SA-09847",
      "code_information": [
        {
          "code": "3602436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PT PUMP 8\\\"\\\" AR-6421",
      "code_information": [
        {
          "code": "3602461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-RING 16\\\" DUR8016W",
      "code_information": [
        {
          "code": "3602526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.2X150 TH P99-193-1215",
      "code_information": [
        {
          "code": "3602570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.0X200MM P99-193-2020",
      "code_information": [
        {
          "code": "3602993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X100MM P99-192-1410",
      "code_information": [
        {
          "code": "3603370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-BIVENTRICULAR BS-101-97",
      "code_information": [
        {
          "code": "3603546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX 3-0 PS-2",
      "code_information": [
        {
          "code": "3603921",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.4X15 MSG14150",
      "code_information": [
        {
          "code": "3604046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 1.6X15 MSG16150",
      "code_information": [
        {
          "code": "3604056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X150MM P99-292-0915",
      "code_information": [
        {
          "code": "3604177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.3X150 SM P99-192-2315",
      "code_information": [
        {
          "code": "3604181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM P99-292-1115",
      "code_information": [
        {
          "code": "3604182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1615",
      "code_information": [
        {
          "code": "3604183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X150MM P99-192-1415",
      "code_information": [
        {
          "code": "3604184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-U-FRAME STRD MT-APU-2.4",
      "code_information": [
        {
          "code": "3604229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADS-LACURA VISCO FOOT",
      "code_information": [
        {
          "code": "3604310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-HEX 10MM 76-10185",
      "code_information": [
        {
          "code": "3604312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-GUARDIAN HEMOSTAT 8215",
      "code_information": [
        {
          "code": "3604336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-WASTE 04369",
      "code_information": [
        {
          "code": "3604367",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K .9X150MM P99-192-0915",
      "code_information": [
        {
          "code": "3604377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG 900-152",
      "code_information": [
        {
          "code": "3604585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD-EX 900-154",
      "code_information": [
        {
          "code": "3604586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY MD 900-151",
      "code_information": [
        {
          "code": "3604587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONE-BIOPSY LG-SHL 900-155",
      "code_information": [
        {
          "code": "3604588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FINGER SMALL 9906",
      "code_information": [
        {
          "code": "3604630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 373,
          "minimum": 78.33,
          "maximum": 273.1106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.1106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CARDIOPLEGIA CA-20010",
      "code_information": [
        {
          "code": "3604878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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          ]
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    },
    {
      "description": "WIRE-K 1.1X150MM P99-192-1115",
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        }
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    {
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    {
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          ]
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        }
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          ]
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        }
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          ]
        }
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    },
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          ]
        }
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          ]
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          ]
        }
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        {
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        }
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          ]
        }
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        }
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          ]
        }
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        {
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        }
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          ]
        }
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        {
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        }
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          ]
        }
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        {
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        }
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          ]
        }
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        {
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        }
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          ]
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        {
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        }
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        }
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        }
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          ]
        }
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    },
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        }
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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        {
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          ]
        }
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    },
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            }
          ]
        }
      ],
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    },
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        {
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        }
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          ]
        }
      ],
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    },
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        },
        {
          "code": "0270",
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        }
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X40X16MM 608240",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X45X16MM 608245",
      "code_information": [
        {
          "code": "3900054",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X45X32MM 608445",
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        {
          "code": "3900055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X50X16MM 608250",
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        {
          "code": "3900056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X50X32MM 608450",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X55X16MM 608255",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 5X120/35TH 5020-6-120",
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        {
          "code": "3900104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 5X180/60TH 5020-8-180",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "PIN-APEX 5X200/60TH 5020-6-200",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 1.65X45/12 5080-1-612",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 1.65X45/20 5080-1-620",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2.0X45/12 5080-2-012",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "PIN-APEX 2.0X45/20 5080-2-020",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE FT  2.7X26MM 656426",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE FT  2.7X36MM 656436",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE FT  2.7X40MM 656440",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE FT  2.7X45MM 656445",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-BONE FT 2.7X8MM 656408",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-NLOCK FT 2.7X70MM 657170",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "FORCEP-RADIAL JAW",
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        {
          "code": "4823650",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR   NM-400U-0525",
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        {
          "code": "4825515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD 3.2MM MT-APU",
      "code_information": [
        {
          "code": "5750663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 273.1106,
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 J305H",
      "code_information": [
        {
          "code": "3012910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL3-0 27\\\" FS-2",
      "code_information": [
        {
          "code": "3033304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-ETHICON         PCP-20",
      "code_information": [
        {
          "code": "3033960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUT-PDS 2-0 Z317H",
      "code_information": [
        {
          "code": "3059073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VIC 2-0           J317H",
      "code_information": [
        {
          "code": "3088957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J329H",
      "code_information": [
        {
          "code": "3088960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y215H",
      "code_information": [
        {
          "code": "3088973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y214H",
      "code_information": [
        {
          "code": "3088974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-RETENTION 450G",
      "code_information": [
        {
          "code": "3088984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 36\\\"        Z346H",
      "code_information": [
        {
          "code": "3088987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y398H",
      "code_information": [
        {
          "code": "3088989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J602H",
      "code_information": [
        {
          "code": "3088995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y346H",
      "code_information": [
        {
          "code": "3088999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL  0         J946G",
      "code_information": [
        {
          "code": "3089001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J603H",
      "code_information": [
        {
          "code": "3089003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J270H",
      "code_information": [
        {
          "code": "3089004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J341H",
      "code_information": [
        {
          "code": "3089009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J338H",
      "code_information": [
        {
          "code": "3089016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J311H",
      "code_information": [
        {
          "code": "3089021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRL 1        Y341H",
      "code_information": [
        {
          "code": "3089036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 0        Y340H",
      "code_information": [
        {
          "code": "3089037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8425H",
      "code_information": [
        {
          "code": "3089050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8424H",
      "code_information": [
        {
          "code": "3089052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0         8412H",
      "code_information": [
        {
          "code": "3089053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8433H",
      "code_information": [
        {
          "code": "3089062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8417H",
      "code_information": [
        {
          "code": "3089070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J633H",
      "code_information": [
        {
          "code": "3089091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0          802H",
      "code_information": [
        {
          "code": "3089130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1         S115H",
      "code_information": [
        {
          "code": "3089137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1          865H",
      "code_information": [
        {
          "code": "3089138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1          813H",
      "code_information": [
        {
          "code": "3089139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J370H",
      "code_information": [
        {
          "code": "3089144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 1       S105H",
      "code_information": [
        {
          "code": "3089149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            K835H",
      "code_information": [
        {
          "code": "3089164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            SA86G",
      "code_information": [
        {
          "code": "3089165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0      852H",
      "code_information": [
        {
          "code": "3089167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     H821H",
      "code_information": [
        {
          "code": "3089171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            A186H",
      "code_information": [
        {
          "code": "3089173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           623H",
      "code_information": [
        {
          "code": "3089176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A184H",
      "code_information": [
        {
          "code": "3089178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3089183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A305H",
      "code_information": [
        {
          "code": "3089185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          A185H",
      "code_information": [
        {
          "code": "3089186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K831H",
      "code_information": [
        {
          "code": "3089193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0           684H",
      "code_information": [
        {
          "code": "3089198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          A183H",
      "code_information": [
        {
          "code": "3089200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        636H",
      "code_information": [
        {
          "code": "3089205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X964H",
      "code_information": [
        {
          "code": "3089208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2        X519H",
      "code_information": [
        {
          "code": "3089213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X518H",
      "code_information": [
        {
          "code": "3089214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0       1674H",
      "code_information": [
        {
          "code": "3089236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1673H",
      "code_information": [
        {
          "code": "3089242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        627H",
      "code_information": [
        {
          "code": "3089245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z339H",
      "code_information": [
        {
          "code": "3089255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0   Z304H",
      "code_information": [
        {
          "code": "3089260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J442H",
      "code_information": [
        {
          "code": "3089274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 1689H",
      "code_information": [
        {
          "code": "3089276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 1            SA87G",
      "code_information": [
        {
          "code": "3089277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2          J880T",
      "code_information": [
        {
          "code": "3089278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2          460T",
      "code_information": [
        {
          "code": "3089298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J214H",
      "code_information": [
        {
          "code": "3089329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J662H",
      "code_information": [
        {
          "code": "3089339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J347H",
      "code_information": [
        {
          "code": "3089347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J335H",
      "code_information": [
        {
          "code": "3089359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 1        X425H",
      "code_information": [
        {
          "code": "3089385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 2-0           Z333H",
      "code_information": [
        {
          "code": "3089395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 626H",
      "code_information": [
        {
          "code": "3089409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685H",
      "code_information": [
        {
          "code": "3500610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    684G",
      "code_information": [
        {
          "code": "3500770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          K872H",
      "code_information": [
        {
          "code": "3501015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 18FR 30CC      266718",
      "code_information": [
        {
          "code": "3507735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 0 PDP340H",
      "code_information": [
        {
          "code": "3526247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-3-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-3-0 PLUS",
      "code_information": [
        {
          "code": "3526254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS PLUS 1 PDP341H",
      "code_information": [
        {
          "code": "3549733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE 4-0 R633H",
      "code_information": [
        {
          "code": "3549987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        635G",
      "code_information": [
        {
          "code": "3555389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           622-H",
      "code_information": [
        {
          "code": "3557329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK O             624H",
      "code_information": [
        {
          "code": "3557386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           661-G",
      "code_information": [
        {
          "code": "3557535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           662-G",
      "code_information": [
        {
          "code": "3557568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON           663-H",
      "code_information": [
        {
          "code": "3557592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 2.0        664G",
      "code_information": [
        {
          "code": "3557990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON            801H",
      "code_information": [
        {
          "code": "3558467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 3-0        1671-H",
      "code_information": [
        {
          "code": "3559001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         B-842-H",
      "code_information": [
        {
          "code": "3560064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J219H",
      "code_information": [
        {
          "code": "3560487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J258H",
      "code_information": [
        {
          "code": "3560490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL          J-416-H",
      "code_information": [
        {
          "code": "3560745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J415H",
      "code_information": [
        {
          "code": "3560840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J417H",
      "code_information": [
        {
          "code": "3561410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0        669H",
      "code_information": [
        {
          "code": "3561418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 3-0  J-944-H",
      "code_information": [
        {
          "code": "3561419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-832-H",
      "code_information": [
        {
          "code": "3561461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         K-833-H",
      "code_information": [
        {
          "code": "3561495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH MONOCRL 2-0   Y259H",
      "code_information": [
        {
          "code": "3562109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3.0    Y-338-H",
      "code_information": [
        {
          "code": "3562123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y416H",
      "code_information": [
        {
          "code": "3562126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 3-0     H822H",
      "code_information": [
        {
          "code": "3562128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 4-0 FS-1    1629H",
      "code_information": [
        {
          "code": "3562140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8683G",
      "code_information": [
        {
          "code": "3562227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           683G",
      "code_information": [
        {
          "code": "3562240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0          K871H",
      "code_information": [
        {
          "code": "3562245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP316H",
      "code_information": [
        {
          "code": "3598241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP945G",
      "code_information": [
        {
          "code": "3598400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 J422H",
      "code_information": [
        {
          "code": "3598401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL SZ 1 36\\\" J519H",
      "code_information": [
        {
          "code": "3598406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS #1 VCP371H",
      "code_information": [
        {
          "code": "3598411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 G181H",
      "code_information": [
        {
          "code": "3598414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1670H",
      "code_information": [
        {
          "code": "3598421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 2-0 VCP195H",
      "code_information": [
        {
          "code": "3598422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ #1 VCP569H",
      "code_information": [
        {
          "code": "3598423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 4.0 VCP310H",
      "code_information": [
        {
          "code": "3598433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0 664H",
      "code_information": [
        {
          "code": "3598435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 J306H",
      "code_information": [
        {
          "code": "3598715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP311H",
      "code_information": [
        {
          "code": "3602123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 663G",
      "code_information": [
        {
          "code": "3602506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 2-0 MCP345H",
      "code_information": [
        {
          "code": "3602920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0   Y303H",
      "code_information": [
        {
          "code": "3603113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 VCP602H",
      "code_information": [
        {
          "code": "3603514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP305H",
      "code_information": [
        {
          "code": "3604136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP422H",
      "code_information": [
        {
          "code": "3604226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 VCP218H",
      "code_information": [
        {
          "code": "3604353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 4-0 VCP434H",
      "code_information": [
        {
          "code": "3604548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP603H",
      "code_information": [
        {
          "code": "3604710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP946H",
      "code_information": [
        {
          "code": "3604711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BLK 3-0 18\\\"\\\" 642G",
      "code_information": [
        {
          "code": "3604940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        X424H",
      "code_information": [
        {
          "code": "3824629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J269H",
      "code_information": [
        {
          "code": "3824633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J232H",
      "code_information": [
        {
          "code": "3824634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J434H",
      "code_information": [
        {
          "code": "3824636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 30\\\"    X444H",
      "code_information": [
        {
          "code": "3824647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 27\\\"    J443H",
      "code_information": [
        {
          "code": "3824648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X411",
      "code_information": [
        {
          "code": "3824706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14,
          "minimum": 2.94,
          "maximum": 10.2508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10.2508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-TOUHY BORST W/SIDE ARM",
      "code_information": [
        {
          "code": "1410050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-FEMORAL ANGIO  DYNJP4119",
      "code_information": [
        {
          "code": "1410800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18GX10CM   G01559",
      "code_information": [
        {
          "code": "1410916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-15      G03955",
      "code_information": [
        {
          "code": "1410919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE 9G EVIVA",
      "code_information": [
        {
          "code": "1495267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SWIVEL PORTEX 625191",
      "code_information": [
        {
          "code": "3002219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT ANT- 1012S",
      "code_information": [
        {
          "code": "3004017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-RANEY SCALP ADULT 20-1037",
      "code_information": [
        {
          "code": "3008833",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRASPER-SUTURE       PMI-TC-SG",
      "code_information": [
        {
          "code": "3010072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SURGISAFE ABSORB WHITE",
      "code_information": [
        {
          "code": "3029216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 10CM    70890856",
      "code_information": [
        {
          "code": "3029291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-STENT 6FR M0061802011",
      "code_information": [
        {
          "code": "3038668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VASCULAR MANIFOLD",
      "code_information": [
        {
          "code": "3050023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0 CX21D",
      "code_information": [
        {
          "code": "3058821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TRU               2C4041",
      "code_information": [
        {
          "code": "3079241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY METER ALL P4PxxULD",
      "code_information": [
        {
          "code": "3084872",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COAG SUCTION      050-005",
      "code_information": [
        {
          "code": "3085551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ELECTROSURGICAL 8\\\"050-010",
      "code_information": [
        {
          "code": "3085595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX OUTFLOW AQL-111",
      "code_information": [
        {
          "code": "3086104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-3/8\\\"X3/32\\\"X8'     3508S",
      "code_information": [
        {
          "code": "3086137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8702H",
      "code_information": [
        {
          "code": "3089122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          JJ31G",
      "code_information": [
        {
          "code": "3089143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C016D",
      "code_information": [
        {
          "code": "3089188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 6-0          1732G",
      "code_information": [
        {
          "code": "3089203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX41",
      "code_information": [
        {
          "code": "3089216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J840D",
      "code_information": [
        {
          "code": "3089388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 CX22D",
      "code_information": [
        {
          "code": "3089700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-AERO          58-79510",
      "code_information": [
        {
          "code": "3284351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHARMBER-HEATER MR290",
      "code_information": [
        {
          "code": "3290069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ9 8.5CM",
      "code_information": [
        {
          "code": "3311077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PULLEY-OVERDOOR LUM101P",
      "code_information": [
        {
          "code": "3311351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-SPIKE PRIMING   101593",
      "code_information": [
        {
          "code": "3500089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-HYPERINFLATION   1/2 LITER",
      "code_information": [
        {
          "code": "3501291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHANNEL ALL JP22xx",
      "code_information": [
        {
          "code": "3512580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 F/PEDS PEDICAP6",
      "code_information": [
        {
          "code": "3512772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LTA MADGIC       MAD600",
      "code_information": [
        {
          "code": "3512793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL LRG     L-35MM",
      "code_information": [
        {
          "code": "3513122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3514273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEEDER-SPECIALNEEDS 80ML 6000S",
      "code_information": [
        {
          "code": "3515912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLD MIC 40M SQ40SK",
      "code_information": [
        {
          "code": "3516131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE ALL SZS     N7s",
      "code_information": [
        {
          "code": "3519400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7089-0844",
      "code_information": [
        {
          "code": "3526221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 J864D",
      "code_information": [
        {
          "code": "3526246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP839D",
      "code_information": [
        {
          "code": "3526344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP838",
      "code_information": [
        {
          "code": "3526348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTOR-ADULT INTUBATED AIRWAY",
      "code_information": [
        {
          "code": "3526527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GROMMET-BEVELED VENT 70241350",
      "code_information": [
        {
          "code": "3527288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS INF-L",
      "code_information": [
        {
          "code": "3541326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS NEO-L",
      "code_information": [
        {
          "code": "3541327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DELIVER MORGAN LENS MT202",
      "code_information": [
        {
          "code": "3541942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD/IV FLUID WARMER L-70",
      "code_information": [
        {
          "code": "3542396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM PREMIE N4901",
      "code_information": [
        {
          "code": "3549181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 24 JP-2234",
      "code_information": [
        {
          "code": "3549296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOCKS-TISSUE FLT-010",
      "code_information": [
        {
          "code": "3549777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIRROR-INSPECTION DIABETIC 081",
      "code_information": [
        {
          "code": "3550157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RAM INFANT N4902",
      "code_information": [
        {
          "code": "3550255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVES-SKIL-CARE GERI SM 5669",
      "code_information": [
        {
          "code": "3550329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH MALE EXTERNAL MECSB01",
      "code_information": [
        {
          "code": "3550510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF LG MDS601LD",
      "code_information": [
        {
          "code": "3550554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE,MERSILINE 4-0 S-2 1779G",
      "code_information": [
        {
          "code": "3550847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT ANES 2L 72\\\"",
      "code_information": [
        {
          "code": "3559130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 S-14",
      "code_information": [
        {
          "code": "3559177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP774D",
      "code_information": [
        {
          "code": "3559182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-UNDER NOSE",
      "code_information": [
        {
          "code": "3559270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2350H",
      "code_information": [
        {
          "code": "3559280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND CHAN 19 JP-2230",
      "code_information": [
        {
          "code": "3559393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHAMBER-HUMIDIFER MR290V",
      "code_information": [
        {
          "code": "3559432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET NEO",
      "code_information": [
        {
          "code": "3559609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         C-017-D",
      "code_information": [
        {
          "code": "3560077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4258705",
      "code_information": [
        {
          "code": "3568756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-COBAN 2LAYER         2094",
      "code_information": [
        {
          "code": "3575850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND UNIVERSAL RT/LT LG",
      "code_information": [
        {
          "code": "3580012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE UNIV 9006-00",
      "code_information": [
        {
          "code": "3580022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3598026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MAC",
      "code_information": [
        {
          "code": "3598027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LAPAROSCOPIC STR 2190J",
      "code_information": [
        {
          "code": "3598116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-POLY OVAL SOFT WIRE",
      "code_information": [
        {
          "code": "3598262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ARTHROGRAM DYNJ07425",
      "code_information": [
        {
          "code": "3598354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 1 VCP741D",
      "code_information": [
        {
          "code": "3598416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-NERVE BLOCK 22G HN3S-80",
      "code_information": [
        {
          "code": "3598440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAG-DISP SUCT 10’ 30-5201",
      "code_information": [
        {
          "code": "3598648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1 VASC1346",
      "code_information": [
        {
          "code": "3598865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/63-74\\\" 1146PP",
      "code_information": [
        {
          "code": "3598976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-NASAL VIP1137380",
      "code_information": [
        {
          "code": "3599139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-NASAL VIP1137381",
      "code_information": [
        {
          "code": "3599142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE RENOVARP GIS-29",
      "code_information": [
        {
          "code": "3599229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 17-22CM",
      "code_information": [
        {
          "code": "3599603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 22-25CM",
      "code_information": [
        {
          "code": "3599604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 25-29CM",
      "code_information": [
        {
          "code": "3599605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 29-36CM",
      "code_information": [
        {
          "code": "3599606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 240014",
      "code_information": [
        {
          "code": "3599773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SSL",
      "code_information": [
        {
          "code": "3600225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1MSL",
      "code_information": [
        {
          "code": "3600226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1LSL",
      "code_information": [
        {
          "code": "3600227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL WIDE EVO1WSL",
      "code_information": [
        {
          "code": "3600228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2SSL",
      "code_information": [
        {
          "code": "3600230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2MSL",
      "code_information": [
        {
          "code": "3600231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ESON NASAL ESN2LSL",
      "code_information": [
        {
          "code": "3600232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CN 10MM HEX P45-940-0001",
      "code_information": [
        {
          "code": "3600608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-JTIP .025X33CM",
      "code_information": [
        {
          "code": "3600780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 2-0 VCP726D",
      "code_information": [
        {
          "code": "3601389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SEDLINE RD",
      "code_information": [
        {
          "code": "3601706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMP SENSING 16FR 119216",
      "code_information": [
        {
          "code": "3601726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PREM CS006",
      "code_information": [
        {
          "code": "3601999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL+ 0 VCPP31D",
      "code_information": [
        {
          "code": "3602463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-INSTRUMENT T50106",
      "code_information": [
        {
          "code": "3603056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63447",
      "code_information": [
        {
          "code": "3603065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63446",
      "code_information": [
        {
          "code": "3603066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F20 63445",
      "code_information": [
        {
          "code": "3603067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
      "code_information": [
        {
          "code": "3603332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-BIOPSY ORT 27550ZAG/10",
      "code_information": [
        {
          "code": "3603541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG GOLD NR30001010",
      "code_information": [
        {
          "code": "3603912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NOMOLINE LH AIRWAY ADAPTER",
      "code_information": [
        {
          "code": "3603959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED W/ PEEP VALVE",
      "code_information": [
        {
          "code": "3603963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADULT W/ PEEP VAL",
      "code_information": [
        {
          "code": "3603964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION C2202",
      "code_information": [
        {
          "code": "3603996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCP840D",
      "code_information": [
        {
          "code": "3604214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROVOX-DILATOR 8341",
      "code_information": [
        {
          "code": "3604745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PERFUSION PUMP 6320",
      "code_information": [
        {
          "code": "3604835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSUFFLATION 120MM",
      "code_information": [
        {
          "code": "3604953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-TRANSDUCER     K11-00096",
      "code_information": [
        {
          "code": "3820165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TEMPSENSING 16FR   117416",
      "code_information": [
        {
          "code": "3822997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL 4FR 20CM G02366",
      "code_information": [
        {
          "code": "3823450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY          000109",
      "code_information": [
        {
          "code": "4820900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION 16G",
      "code_information": [
        {
          "code": "4825435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 179,
          "minimum": 37.59,
          "maximum": 131.0638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.0638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-VASCULAR 6MM X 7MM X 5FR",
      "code_information": [
        {
          "code": "1415480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-ANASTOCLIP LARGE 15CM",
      "code_information": [
        {
          "code": "3000773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-PASSER            8591-38",
      "code_information": [
        {
          "code": "3006601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE TISSUE REMOVAL",
      "code_information": [
        {
          "code": "3010310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED ASNIS III",
      "code_information": [
        {
          "code": "3012111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.5MM  702450",
      "code_information": [
        {
          "code": "3012114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST ASNIS III 6.5MM",
      "code_information": [
        {
          "code": "3012151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-HELI-FX            SG-64",
      "code_information": [
        {
          "code": "3016110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE EMG 8050015",
      "code_information": [
        {
          "code": "3022950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAK-CONFIDENCE PLUS",
      "code_information": [
        {
          "code": "3029292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARTHREX ANGEL BMC",
      "code_information": [
        {
          "code": "3058674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 8MMX24CM",
      "code_information": [
        {
          "code": "3058757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 6MMX17CM",
      "code_information": [
        {
          "code": "3058758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 4MMX7CM",
      "code_information": [
        {
          "code": "3058776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MM X xCM",
      "code_information": [
        {
          "code": "3058777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 6MM X xxCM",
      "code_information": [
        {
          "code": "3058840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 CX ALL",
      "code_information": [
        {
          "code": "3058847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MMX15CM",
      "code_information": [
        {
          "code": "3058884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-VERTEX DRILL 2.4MM",
      "code_information": [
        {
          "code": "3059197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-CAROTID ALL     2000-00s",
      "code_information": [
        {
          "code": "3079680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-INTERNAL EEA   EEAXL25",
      "code_information": [
        {
          "code": "3081425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-TVT DEVICE .5\\\"X18\\\" 810041",
      "code_information": [
        {
          "code": "3083229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EMBLEM TUNNELING 4711",
      "code_information": [
        {
          "code": "3084601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-PROGEL PGPS002",
      "code_information": [
        {
          "code": "3091508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER XPEEDA AC-1000729",
      "code_information": [
        {
          "code": "3526375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSSEPTAL NTK-711-8545",
      "code_information": [
        {
          "code": "3527245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 03.033.004",
      "code_information": [
        {
          "code": "3527874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-APEX 11CM 5500-25B-114",
      "code_information": [
        {
          "code": "3527983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-FEMORAL AUG SZ6 154906002",
      "code_information": [
        {
          "code": "3549097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-SPIN ACCESS INS-5900",
      "code_information": [
        {
          "code": "3550000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-INSERTER",
      "code_information": [
        {
          "code": "3550237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-VASC 14X7MM SBT1402D",
      "code_information": [
        {
          "code": "3550693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER ELEVATE 8340155",
      "code_information": [
        {
          "code": "3559412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8013090",
      "code_information": [
        {
          "code": "3559559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-9WX7L AR-8717-0907",
      "code_information": [
        {
          "code": "3598104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER SM 4934-8-100",
      "code_information": [
        {
          "code": "3600215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7FR 4",
      "code_information": [
        {
          "code": "3600789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7F 34",
      "code_information": [
        {
          "code": "3600790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX 45MM 227445500",
      "code_information": [
        {
          "code": "3600946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PREP 4.2MM 0909-100-042",
      "code_information": [
        {
          "code": "3601029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EXP 4.2MM 0909-200-042",
      "code_information": [
        {
          "code": "3601030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-16 HLW 03.037.004S",
      "code_information": [
        {
          "code": "3601121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-ROCKER MD 4934-8-140",
      "code_information": [
        {
          "code": "3601242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOCLOT EPK2303-01",
      "code_information": [
        {
          "code": "3601392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AUX CBL PLT 94-1500-04-S",
      "code_information": [
        {
          "code": "3601589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-DEBRIDEMENT DDBK02",
      "code_information": [
        {
          "code": "3601755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-GUIDE VDR 80-0049",
      "code_information": [
        {
          "code": "3602651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-DELIVERY STRBL-14F-075",
      "code_information": [
        {
          "code": "3603178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-AO CONN P65-001-0001-SK",
      "code_information": [
        {
          "code": "3603438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM RC P01-DWL-0915",
      "code_information": [
        {
          "code": "3604386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FIBER-OPTIC BALLOON 7.5FR",
      "code_information": [
        {
          "code": "3827764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "CATH-FIBEROPTIC BALLOON 8.0FR",
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        {
          "code": "3827765",
          "type": "LOCAL"
        },
        {
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          "type": "RC"
        }
      ],
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            }
          ]
        }
      ],
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    },
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        }
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          ]
        }
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    {
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        {
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          ]
        }
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    {
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        {
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          ]
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          ]
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        {
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        {
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        {
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        {
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        {
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    },
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        {
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              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 1.7X8MM 662608",
      "code_information": [
        {
          "code": "3900201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-EMERG 1.9X10MM 662710",
      "code_information": [
        {
          "code": "3900202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-EMERG 1.9X12MM 662712",
      "code_information": [
        {
          "code": "3900203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-EMERG 1.9X15MM 662705",
      "code_information": [
        {
          "code": "3900204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-EMERG 1.9X8MM 662708",
      "code_information": [
        {
          "code": "3900205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X22MM 663822",
      "code_information": [
        {
          "code": "3900206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X24MM 663824",
      "code_information": [
        {
          "code": "3900207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X26MM 663826",
      "code_information": [
        {
          "code": "3900208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/1.7MM 57-05202",
      "code_information": [
        {
          "code": "3900368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/LT 57-05221",
      "code_information": [
        {
          "code": "3900369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/RT 57-05220",
      "code_information": [
        {
          "code": "3900370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 6H/1.7MM 57-05240",
      "code_information": [
        {
          "code": "3900371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 10H/1.7 57-05262",
      "code_information": [
        {
          "code": "3900372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 7H/1.7MM 57-05260",
      "code_information": [
        {
          "code": "3900373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Y 7H/1.7MM 57-05270",
      "code_information": [
        {
          "code": "3900374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 5H/2.3MM 57-13405",
      "code_information": [
        {
          "code": "3900381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/2.3MM 57-13408",
      "code_information": [
        {
          "code": "3900382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 8H/2.3MM 57-13410",
      "code_information": [
        {
          "code": "3900383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-13421",
      "code_information": [
        {
          "code": "3900385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13440",
      "code_information": [
        {
          "code": "3900386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13450",
      "code_information": [
        {
          "code": "3900387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13906",
      "code_information": [
        {
          "code": "3900389",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 2H/23MM 626672",
      "code_information": [
        {
          "code": "3900390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 3H/35MM",
      "code_information": [
        {
          "code": "3900391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 8.0MM LG AO",
      "code_information": [
        {
          "code": "3900392",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/2.3 57-10190",
      "code_information": [
        {
          "code": "3900393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/RT 57-10120",
      "code_information": [
        {
          "code": "3900395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3MM 57-10140",
      "code_information": [
        {
          "code": "3900396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-SCREW F/ 2.7MM AO 703899",
      "code_information": [
        {
          "code": "3900399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-SCREW F/ 3.5MM AO 703898",
      "code_information": [
        {
          "code": "3900400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 4H/47MM",
      "code_information": [
        {
          "code": "3900401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 4H 629504",
      "code_information": [
        {
          "code": "3900402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 4H 629544",
      "code_information": [
        {
          "code": "3900403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2+2H/1.7 57-05297",
      "code_information": [
        {
          "code": "3900406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/1.7 57-052920",
      "code_information": [
        {
          "code": "3900407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7 57-05295",
      "code_information": [
        {
          "code": "3900410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/1.7/LT 57-05283",
      "code_information": [
        {
          "code": "3900411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/2.3MM 57-10402",
      "code_information": [
        {
          "code": "3900414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-10420",
      "code_information": [
        {
          "code": "3900417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10421",
      "code_information": [
        {
          "code": "3900418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10460",
      "code_information": [
        {
          "code": "3900420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP Y 6H/2.3MM 57-10470",
      "code_information": [
        {
          "code": "3900421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5641,
          "minimum": 1184.61,
          "maximum": 4130.3402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4130.3402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE    16G X 12.5",
      "code_information": [
        {
          "code": "1410723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANTENNA-PROGRAMMER       37092",
      "code_information": [
        {
          "code": "3000651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM        310.111",
      "code_information": [
        {
          "code": "3002241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2       AR-8944-22",
      "code_information": [
        {
          "code": "3002251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0          316.396",
      "code_information": [
        {
          "code": "3002271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM         310.31",
      "code_information": [
        {
          "code": "3002300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1MM         310.11",
      "code_information": [
        {
          "code": "3002784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM         310.26",
      "code_information": [
        {
          "code": "3002788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM         310.44",
      "code_information": [
        {
          "code": "3002798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW             511.9xxS",
      "code_information": [
        {
          "code": "3003266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS  03.000.3xxS",
      "code_information": [
        {
          "code": "3003268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 532.066S",
      "code_information": [
        {
          "code": "3003293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 225 ML04253",
      "code_information": [
        {
          "code": "3003420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-LIVANOVA 125ML 04251",
      "code_information": [
        {
          "code": "3003421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 4MM PAL-404LLB",
      "code_information": [
        {
          "code": "3004044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-304LLB",
      "code_information": [
        {
          "code": "3004046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO PAL-304LM",
      "code_information": [
        {
          "code": "3004053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPORT II PAL-406LS",
      "code_information": [
        {
          "code": "3004250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHOLANGIOGRAM       C100",
      "code_information": [
        {
          "code": "3005220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR TITANIUM  FV012T",
      "code_information": [
        {
          "code": "3009771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3          316.402",
      "code_information": [
        {
          "code": "3012305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM AR-4160-35",
      "code_information": [
        {
          "code": "3012347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.141",
      "code_information": [
        {
          "code": "3012354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 310.25",
      "code_information": [
        {
          "code": "3012405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-558",
      "code_information": [
        {
          "code": "3012475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 3.2X300MM",
      "code_information": [
        {
          "code": "3014238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUGE 03.804.5x",
      "code_information": [
        {
          "code": "3020805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PREP     546102000",
      "code_information": [
        {
          "code": "3020926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 24FR      880-213",
      "code_information": [
        {
          "code": "3021819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE WATER",
      "code_information": [
        {
          "code": "3023171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE  2839-xx-xxx",
      "code_information": [
        {
          "code": "3027302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTROSURG 134006",
      "code_information": [
        {
          "code": "3029511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL  1.5MM W/8.0MM STOP",
      "code_information": [
        {
          "code": "3058520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM CALIBRATED",
      "code_information": [
        {
          "code": "3058937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 19 G05880",
      "code_information": [
        {
          "code": "3058996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8943-",
      "code_information": [
        {
          "code": "3059000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-AIRWAY EXCH 8F G07833",
      "code_information": [
        {
          "code": "3059157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER 11 G06732",
      "code_information": [
        {
          "code": "3059264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-4.5MM INCISOR PLUS",
      "code_information": [
        {
          "code": "3060481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 5MM          CB5LT",
      "code_information": [
        {
          "code": "3079768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DOYLE II AIRWY 15-24055",
      "code_information": [
        {
          "code": "3080045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-                TLC-55",
      "code_information": [
        {
          "code": "3081528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30GRN     TX30G",
      "code_information": [
        {
          "code": "3081555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 30BL      TX30B",
      "code_information": [
        {
          "code": "3081557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7MM AR-8916-14",
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        {
          "code": "3087940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CALIBRATED DRILL 2.5",
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        {
          "code": "3087942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER   60-6085-20x",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TUBE EXCHANGER     G3640x",
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        {
          "code": "3509540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TRACHEAL TUBE 15FR",
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        {
          "code": "3521005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BACK TABLE     DYNJ31777A",
      "code_information": [
        {
          "code": "3526152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-C-SECTION      DYNJ31780C",
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        {
          "code": "3526153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VASCULAR LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3526426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRANSDUCER TRUWAVE PX272",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE UNTHREAD 2X200MM",
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        {
          "code": "3526988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 16/18 FR 96551",
      "code_information": [
        {
          "code": "3527178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET",
      "code_information": [
        {
          "code": "3527263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SOMA ADULT SAFB-SM/USA",
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        {
          "code": "3527866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DELIVERY NAVIFLEX 7FR.",
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        {
          "code": "3527884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EPG CONNECTOR 53912D",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLOWSAFE II",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-NAIL 1806-1406S",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VORTRAN RESUSCITATION",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "BIT-DRILL 2.4MM 2020-00-335",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-DRILLING COMP EL-DTS",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SPEED FEMORAL AE-1605",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SELECTOR-VEIN 57538CSV-WOR",
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        {
          "code": "3559121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-INSTRUMENT 0306-531-000",
      "code_information": [
        {
          "code": "3559266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-EXCELSIUS ARM 6143.2001S",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 187.95,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-MONITOR 6143.2003S",
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          "code": "3559498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-TRANSFUSION EXCHANGE",
      "code_information": [
        {
          "code": "3571501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR CARE XL MULTI-USE",
      "code_information": [
        {
          "code": "3598079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUBE-POLAR W/KNEE WRAP",
      "code_information": [
        {
          "code": "3598180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 94725",
      "code_information": [
        {
          "code": "3598197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE MIXTURE",
      "code_information": [
        {
          "code": "3598303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTYCORE 16GX7.5CM",
      "code_information": [
        {
          "code": "3598364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELBOW TRIMANO AR-1646",
      "code_information": [
        {
          "code": "3598377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CAN 1.7/2.0 DRILL 45-20011",
      "code_information": [
        {
          "code": "3598514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 10ML GIS-59",
      "code_information": [
        {
          "code": "3599411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.1X150MM 03.333.001",
      "code_information": [
        {
          "code": "3599532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPAP BUBBLE MR290 CHAMBER",
      "code_information": [
        {
          "code": "3599616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.5X150MM QC 03.133.109",
      "code_information": [
        {
          "code": "3599727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-90° SAG 2296-003-109S2",
      "code_information": [
        {
          "code": "3599964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3600835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 16H 76-9103",
      "code_information": [
        {
          "code": "3600836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 24H 76-9104",
      "code_information": [
        {
          "code": "3600837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB NTHRD AR-18800-11",
      "code_information": [
        {
          "code": "3600896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE STER 03.804.519S",
      "code_information": [
        {
          "code": "3600903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G ACCESS 03.804.517S",
      "code_information": [
        {
          "code": "3600911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X330 S0100-000",
      "code_information": [
        {
          "code": "3601632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FISTULA FUNNEL",
      "code_information": [
        {
          "code": "3601648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-10G SIDE BVT 03.804.520S",
      "code_information": [
        {
          "code": "3601878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE RUNTHRU 180 25-5211",
      "code_information": [
        {
          "code": "3601952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LINE ARTERIAL ART356",
      "code_information": [
        {
          "code": "3602029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION PD-IT",
      "code_information": [
        {
          "code": "3602078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OIL-BIENAIR LUBRIFLUID 1600064",
      "code_information": [
        {
          "code": "3602105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OSTECORE 16G X 16.5",
      "code_information": [
        {
          "code": "3602125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.7MM AR-8827D-01",
      "code_information": [
        {
          "code": "3602345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 3.2X300S NTHRD 702463S",
      "code_information": [
        {
          "code": "3602409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL",
      "code_information": [
        {
          "code": "3602464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREDED AR-18800-11T",
      "code_information": [
        {
          "code": "3602495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-5 MREYE G36405",
      "code_information": [
        {
          "code": "3602688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-3 MREYE G42419",
      "code_information": [
        {
          "code": "3602689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3602820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G BVL 0306-331-000",
      "code_information": [
        {
          "code": "3603302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE -.9MM AR-7524C",
      "code_information": [
        {
          "code": "3604464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DBL 4X30/10 PAL-405LL",
      "code_information": [
        {
          "code": "3604617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-8x30/8 PAL-402LL",
      "code_information": [
        {
          "code": "3604619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GLIDESHEATH RM*ES6J10HAT",
      "code_information": [
        {
          "code": "3824107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X55MM 657055",
      "code_information": [
        {
          "code": "3900358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION RX  M00566670",
      "code_information": [
        {
          "code": "4822473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 895,
          "minimum": 187.95,
          "maximum": 655.319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 655.319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-COAXIAL BIPSY 946x-VC-006",
      "code_information": [
        {
          "code": "1416380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OPTIFIX-ABSORBABLE 0113126",
      "code_information": [
        {
          "code": "3000012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 7.3     310.495",
      "code_information": [
        {
          "code": "3002265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TRICUT LARYNGEAL 4MM",
      "code_information": [
        {
          "code": "3003289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OXFORD SAW 506298",
      "code_information": [
        {
          "code": "3003294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-TUR PK           786500",
      "code_information": [
        {
          "code": "3003816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 96370-023",
      "code_information": [
        {
          "code": "3004233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-020",
      "code_information": [
        {
          "code": "3008516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 11X280       357.404",
      "code_information": [
        {
          "code": "3012311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL FLEX     2274-25-500",
      "code_information": [
        {
          "code": "3012384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 7.0X3.2",
      "code_information": [
        {
          "code": "3012900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-HALO CUTTING HACF-0533",
      "code_information": [
        {
          "code": "3013285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-EVICEL FIBRIN SEALANT 3905",
      "code_information": [
        {
          "code": "3021100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-SEALER 5MM     LF1637",
      "code_information": [
        {
          "code": "3021738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-TUR       784415 & 784515",
      "code_information": [
        {
          "code": "3021867",
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    {
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    {
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    {
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    {
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      "service_type": "CDM"
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    {
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    {
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    {
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        }
      ],
      "service_type": "CDM"
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    {
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    {
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    {
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      ],
      "service_type": "CDM"
    },
    {
      "description": "ITEM-STRAIGHT 5450800307",
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-UNIV SONIC 5450815114",
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          "type": "RC"
        }
      ],
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        {
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            {
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-VENTRIC PACING    D98100",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.915S",
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        },
        {
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        }
      ],
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        {
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            {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-7.0 CANNULATED 400146",
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          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSSEPTAL RF",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER A-2816",
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        }
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        {
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 10MM 03.037.021",
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        },
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 550 AC-10030120",
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          "code": "3549756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRING 675.705S",
      "code_information": [
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          "code": "3550106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-8\\\" INSULATED 675.706S",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIPOLAR 675.170S",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
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          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 698.605S",
      "code_information": [
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          "code": "3550117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER/SHAVER-ALL",
      "code_information": [
        {
          "code": "3550238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HAMMER-SLAP 694.008",
      "code_information": [
        {
          "code": "3550243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-DIRECT MEASURE 702495",
      "code_information": [
        {
          "code": "3550617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-HELIX 6.5 ADVANCE 222313",
      "code_information": [
        {
          "code": "3550751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.7X160 A-8004.01",
      "code_information": [
        {
          "code": "3550825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-DRIVER 4 CANN A-8004.11",
      "code_information": [
        {
          "code": "3550827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-LIGASURE 37CM LF1944",
      "code_information": [
        {
          "code": "3559070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONVEX 16MM XFR004216",
      "code_information": [
        {
          "code": "3559091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-WIRELESS CELL EX1151",
      "code_information": [
        {
          "code": "3559233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-15MM/3.5OS 9159.3035",
      "code_information": [
        {
          "code": "3559597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 2.0",
      "code_information": [
        {
          "code": "3559670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA       PRE1001US",
      "code_information": [
        {
          "code": "3566817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40B GCS40B",
      "code_information": [
        {
          "code": "3598106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM 03.333.103",
      "code_information": [
        {
          "code": "3598147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-STRT TIP BAYON 1590-01",
      "code_information": [
        {
          "code": "3598218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH",
      "code_information": [
        {
          "code": "3598452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SUREFORM 60 480460",
      "code_information": [
        {
          "code": "3598611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 27CM APYX-27-TP",
      "code_information": [
        {
          "code": "3598956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-1X10.5MM BI 632.678S",
      "code_information": [
        {
          "code": "3599051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERCLAGE AR-7268",
      "code_information": [
        {
          "code": "3599170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-CERCLAGE AR-7268T",
      "code_information": [
        {
          "code": "3599171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM 03.333.102",
      "code_information": [
        {
          "code": "3599533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-NANO 125MM AR-3210-0043",
      "code_information": [
        {
          "code": "3600299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-MINI COREDX M00515220",
      "code_information": [
        {
          "code": "3600762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR CVD GCS40G",
      "code_information": [
        {
          "code": "3600838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-LARGE DV2012-LF",
      "code_information": [
        {
          "code": "3600953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-8-13MM P99-110-0813",
      "code_information": [
        {
          "code": "3601104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-UNIVERSAL PAD ARTICGEL",
      "code_information": [
        {
          "code": "3601634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIBER OPTIC PTEYE-1",
      "code_information": [
        {
          "code": "3602127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE IRR F/PM2 58PM2SLV",
      "code_information": [
        {
          "code": "3602337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE 45\\\" HAR745",
      "code_information": [
        {
          "code": "3602909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC ACE HAR736",
      "code_information": [
        {
          "code": "3602910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PREVENA 13CM PRE1101US",
      "code_information": [
        {
          "code": "3603187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 11G NN-1000",
      "code_information": [
        {
          "code": "3603528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SLEEVE/FIBER 13G NN-1001",
      "code_information": [
        {
          "code": "3603586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY MAX M00546470",
      "code_information": [
        {
          "code": "3603811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL M00546550",
      "code_information": [
        {
          "code": "3603812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-RETRIEVAL M00546560",
      "code_information": [
        {
          "code": "3603813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-8MM/CV SF30 488530",
      "code_information": [
        {
          "code": "3603862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY 115CM G48240",
      "code_information": [
        {
          "code": "3603969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 25 LS96555-025",
      "code_information": [
        {
          "code": "3604574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SUPERLOOP TUR 784415",
      "code_information": [
        {
          "code": "3604601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-AO T8 93MM 542011",
      "code_information": [
        {
          "code": "3604892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-SD T20 93MM 542066",
      "code_information": [
        {
          "code": "3604973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BG 6MM ABS-8000-06",
      "code_information": [
        {
          "code": "3605017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-3 SYS REFERENCE   CREFP6",
      "code_information": [
        {
          "code": "3824414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X6MM 656306",
      "code_information": [
        {
          "code": "3900339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X70MM 656370",
      "code_information": [
        {
          "code": "3900340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/178MM/RT 627490",
      "code_information": [
        {
          "code": "3900604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/173MM/RT 627338",
      "code_information": [
        {
          "code": "3900605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DEC BRIDGE 8H/RT 628068",
      "code_information": [
        {
          "code": "3900606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 6H/LT 628146",
      "code_information": [
        {
          "code": "3900607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/151MM/RT 627238",
      "code_information": [
        {
          "code": "3900629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 6H/166MM/LT 627606",
      "code_information": [
        {
          "code": "3900631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 6H/166MM/RT 627636",
      "code_information": [
        {
          "code": "3900632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3356,
          "minimum": 704.76,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 12H/202MM/RT 627242",
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        {
          "code": "3900633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 8H/202MM/LT 627608",
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        {
          "code": "3900634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 12H/274MM/RT 627642",
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        {
          "code": "3900635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 704.76,
          "maximum": 2457.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2457.2632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
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        {
          "code": "1100160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYN            ALLSZs",
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        {
          "code": "1100275",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC PED 10FR    8010",
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        {
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 12FR PEDS   8012",
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        {
          "code": "1102046",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 95.186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK BABY",
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        {
          "code": "1102135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC 3-LUMEN PWR INJ SAFET",
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        {
          "code": "1110365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 561.5974,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH LUMEN 4FR    AK-14402",
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          "code": "1110376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 19G X .75",
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        {
          "code": "1113245",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 51.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS          G04153",
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        {
          "code": "1113258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 316.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-FOREIGN BODY   FB-5000",
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        {
          "code": "1115735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 837,
          "minimum": 175.77,
          "maximum": 612.8514,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 612.8514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEONATE TUBE RESV",
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        {
          "code": "1115845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATHETER CRICOTHYROTOMY",
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        {
          "code": "1118135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 344.19,
          "maximum": 1200.0758,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1200.0758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-HANGING CAST LG 1180LPP",
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        {
          "code": "1118520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 55.6472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
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        {
          "code": "1118720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
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        {
          "code": "1118735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 153.762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "#1855G 5-0 ETHILON PC-1",
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        {
          "code": "1118792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 49,
          "minimum": 10.29,
          "maximum": 35.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 35.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EVAC/DRAIN 1-BTL  62287",
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        {
          "code": "1118801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED       8CFN",
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        {
          "code": "1118955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 71.19,
          "maximum": 248.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 248.2158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 8.61,
          "maximum": 30.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 30.0202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
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        {
          "code": "1119800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 48,
          "minimum": 10.08,
          "maximum": 35.1456,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 35.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-15      G00012",
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        {
          "code": "1410067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINL 22X20     G03542",
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        {
          "code": "1410472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 256,
          "minimum": 53.76,
          "maximum": 187.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 187.4432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CUSTOM WASTE BAG",
      "code_information": [
        {
          "code": "1410792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 136.9214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-INDIGO W/TUBING IAPS2",
      "code_information": [
        {
          "code": "1410803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1768.9952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INFUSION MRI          1056",
      "code_information": [
        {
          "code": "1410839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 176.4602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE ADAPTER MRI   1057",
      "code_information": [
        {
          "code": "1410840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 155.2264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18G 20CM   G01047",
      "code_information": [
        {
          "code": "1410918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 115.6876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1411090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18-15      G03954",
      "code_information": [
        {
          "code": "1411193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 158.8874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MONOPTY 18X10    121810",
      "code_information": [
        {
          "code": "1411612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 221.1244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JAR-COPLIN PP STAIN     S90130",
      "code_information": [
        {
          "code": "1411903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE .010-.038   TD01",
      "code_information": [
        {
          "code": "1412325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-STAYFIX SMALL    680-ME",
      "code_information": [
        {
          "code": "1412330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 114.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL IV 6FR   48-152",
      "code_information": [
        {
          "code": "1412380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL ALL 48-100's",
      "code_information": [
        {
          "code": "1412394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX ALL SZ",
      "code_information": [
        {
          "code": "1413165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 432.7302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX ALL SZ",
      "code_information": [
        {
          "code": "1413170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 523,
          "minimum": 109.83,
          "maximum": 382.9406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 382.9406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-20      G00810",
      "code_information": [
        {
          "code": "1414825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN ALL SZS G01xxx",
      "code_information": [
        {
          "code": "1414845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY ALL SZS",
      "code_information": [
        {
          "code": "1414866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 311.9172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-10      G01112",
      "code_information": [
        {
          "code": "1414935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "1414990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 166.9416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X     C20xxA",
      "code_information": [
        {
          "code": "1414995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-IV SILVERSITE 1X7MM",
      "code_information": [
        {
          "code": "1415449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT GASTRO INITIAL SM",
      "code_information": [
        {
          "code": "1415943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 987,
          "minimum": 207.27,
          "maximum": 722.6814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 722.6814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-150 ML ILLUMENA 900103",
      "code_information": [
        {
          "code": "1416100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGIOGRAPHY    MCBK001-07",
      "code_information": [
        {
          "code": "1416236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 783,
          "minimum": 164.43,
          "maximum": 573.3126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 573.3126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22FR   0250-22",
      "code_information": [
        {
          "code": "1416370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENTUIT THRIVE 14F",
      "code_information": [
        {
          "code": "1416371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 713,
          "minimum": 149.73,
          "maximum": 522.0586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 522.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-INDIGO             IST3",
      "code_information": [
        {
          "code": "1416377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2920,
          "minimum": 613.2,
          "maximum": 2138.024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2138.024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1419101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX11C",
      "code_information": [
        {
          "code": "1419112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX15C",
      "code_information": [
        {
          "code": "1419113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 20GX15C",
      "code_information": [
        {
          "code": "1419114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX11C",
      "code_information": [
        {
          "code": "1419116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX15C",
      "code_information": [
        {
          "code": "1419118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 601,
          "minimum": 126.21,
          "maximum": 440.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 440.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX20C",
      "code_information": [
        {
          "code": "1419119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 601,
          "minimum": 126.21,
          "maximum": 440.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 440.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY  20GX11C",
      "code_information": [
        {
          "code": "1419293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 451,
          "minimum": 94.71,
          "maximum": 330.2222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 330.2222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-BIOPSY EVIVA 9G",
      "code_information": [
        {
          "code": "1495152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-TISSUE ATEC        TF-1",
      "code_information": [
        {
          "code": "1495228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-EVIVA STX   0913-12T",
      "code_information": [
        {
          "code": "1495304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE MULTICARE  MME-00347",
      "code_information": [
        {
          "code": "1495418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC",
      "code_information": [
        {
          "code": "2395902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 80.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC 50MM",
      "code_information": [
        {
          "code": "2395904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 80.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAT-SURGISAFE ABSORBANT FLOOR",
      "code_information": [
        {
          "code": "3000001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 323,
          "minimum": 67.83,
          "maximum": 236.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 236.5006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-FULL RADIUS 5.5MM",
      "code_information": [
        {
          "code": "3000006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO               2C4040",
      "code_information": [
        {
          "code": "3000090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CONFIDENCE 2839-99-002",
      "code_information": [
        {
          "code": "3000520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-HEMOSTASES  HC0001",
      "code_information": [
        {
          "code": "3000742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1597,
          "minimum": 335.37,
          "maximum": 1169.3234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1169.3234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-CLIP MED/LG 20 SMC",
      "code_information": [
        {
          "code": "3000753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 737.3254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP PK AM0004",
      "code_information": [
        {
          "code": "3000760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 186.711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP    AM0005",
      "code_information": [
        {
          "code": "3000762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 234.304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP  DISP   MCM20",
      "code_information": [
        {
          "code": "3000765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 518,
          "minimum": 108.78,
          "maximum": 379.2796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 379.2796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP LARGE MCL20",
      "code_information": [
        {
          "code": "3000766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 553,
          "minimum": 116.13,
          "maximum": 404.9066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 404.9066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP SM MCS20",
      "code_information": [
        {
          "code": "3000767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 569,
          "minimum": 119.49,
          "maximum": 416.6218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 416.6218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-AUTOMATIC 5MM AE05ML",
      "code_information": [
        {
          "code": "3000770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 948.199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSISTANT-SUTURE 5MM     SW100",
      "code_information": [
        {
          "code": "3000865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1311,
          "minimum": 275.31,
          "maximum": 959.9142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 959.9142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-ANCHOR TISSUE ROBOTIC",
      "code_information": [
        {
          "code": "3001135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 475.1978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-ENDOPOUCH 10MM POUCH",
      "code_information": [
        {
          "code": "3001190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-DISPOSA 3MM       DBL-311",
      "code_information": [
        {
          "code": "3001371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 176.4602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IPRISM IPC05",
      "code_information": [
        {
          "code": "3001669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAR-TIBIAL LOCKING      141205",
      "code_information": [
        {
          "code": "3002092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1493,
          "minimum": 313.53,
          "maximum": 1093.1746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1093.1746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 1.9X120 390-201",
      "code_information": [
        {
          "code": "3002152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1576,
          "minimum": 330.96,
          "maximum": 1153.9472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1153.9472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOFILTER-ASP FLTR",
      "code_information": [
        {
          "code": "3002210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 508,
          "minimum": 106.68,
          "maximum": 371.9576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 371.9576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CEMENT-COMPACT VACUUM",
      "code_information": [
        {
          "code": "3002214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 956.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           315.48",
      "code_information": [
        {
          "code": "3002244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.2      310.65",
      "code_information": [
        {
          "code": "3002246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MINI DRILL AT2M-1813",
      "code_information": [
        {
          "code": "3002257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1592.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145   03.010.104",
      "code_information": [
        {
          "code": "3002260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1668,
          "minimum": 350.28,
          "maximum": 1221.3096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1221.3096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    351.27",
      "code_information": [
        {
          "code": "3002270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3542,
          "minimum": 743.82,
          "maximum": 2593.4524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2593.4524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM      03.010.036",
      "code_information": [
        {
          "code": "3002274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3373,
          "minimum": 708.33,
          "maximum": 2469.7106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2469.7106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.060",
      "code_information": [
        {
          "code": "3002289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2190,
          "minimum": 459.9,
          "maximum": 1603.518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1603.518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5           310.23",
      "code_information": [
        {
          "code": "3002291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 937,
          "minimum": 196.77,
          "maximum": 686.0714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 686.0714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM         310.19",
      "code_information": [
        {
          "code": "3002294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 949,
          "minimum": 199.29,
          "maximum": 694.8578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 694.8578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MMX150MM  511.417",
      "code_information": [
        {
          "code": "3002302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1642,
          "minimum": 344.82,
          "maximum": 1202.2724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1202.2724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2 ALL 1806-4200s",
      "code_information": [
        {
          "code": "3002305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1134,
          "minimum": 238.14,
          "maximum": 830.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 830.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X180MM 1806-4270S",
      "code_information": [
        {
          "code": "3002306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 890.3552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR        5091-206",
      "code_information": [
        {
          "code": "3002318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 206.4804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR",
      "code_information": [
        {
          "code": "3002324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 83.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-STEP DRILL         357.403",
      "code_information": [
        {
          "code": "3002361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3578,
          "minimum": 751.38,
          "maximum": 2619.8116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2619.8116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.4     310.530",
      "code_information": [
        {
          "code": "3002365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1282,
          "minimum": 269.22,
          "maximum": 938.6804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 938.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           1806-5020S",
      "code_information": [
        {
          "code": "3002379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1219,
          "minimum": 255.99,
          "maximum": 892.5518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 892.5518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM        388.394",
      "code_information": [
        {
          "code": "3002383",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         60-20385",
      "code_information": [
        {
          "code": "3002391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 806.8844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 03.113.024",
      "code_information": [
        {
          "code": "3002394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1440,
          "minimum": 302.4,
          "maximum": 1054.368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1054.368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 03.113.023",
      "code_information": [
        {
          "code": "3002399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1440,
          "minimum": 302.4,
          "maximum": 1054.368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1054.368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM 703542",
      "code_information": [
        {
          "code": "3002400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 940.1448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3MM 703541",
      "code_information": [
        {
          "code": "3002402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1335,
          "minimum": 280.35,
          "maximum": 977.487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 977.487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5085-2-032",
      "code_information": [
        {
          "code": "3002403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM 5085-2-040",
      "code_information": [
        {
          "code": "3002410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 1.7MM",
      "code_information": [
        {
          "code": "3002760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1755,
          "minimum": 368.55,
          "maximum": 1285.011,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1285.011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO        1806-5000S",
      "code_information": [
        {
          "code": "3002772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1103,
          "minimum": 231.63,
          "maximum": 807.6166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 807.6166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM     03.010.061",
      "code_information": [
        {
          "code": "3002776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2190,
          "minimum": 459.9,
          "maximum": 1603.518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1603.518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM    03.010.101S",
      "code_information": [
        {
          "code": "3002777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1592.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.6x",
      "code_information": [
        {
          "code": "3002779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2769,
          "minimum": 581.49,
          "maximum": 2027.4618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2027.4618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL W/STOP ALL   324.15x",
      "code_information": [
        {
          "code": "3002780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2797,
          "minimum": 587.37,
          "maximum": 2047.9634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2047.9634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.68",
      "code_information": [
        {
          "code": "3002782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2977,
          "minimum": 625.17,
          "maximum": 2179.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2179.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 17MM    357.394",
      "code_information": [
        {
          "code": "3002785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4976,
          "minimum": 1044.96,
          "maximum": 3643.4272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3643.4272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM         700347",
      "code_information": [
        {
          "code": "3002791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1337,
          "minimum": 280.77,
          "maximum": 978.9514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 978.9514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1MM         702742",
      "code_information": [
        {
          "code": "3002793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1019,
          "minimum": 213.99,
          "maximum": 746.1118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 746.1118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X110MM     310.35",
      "code_information": [
        {
          "code": "3002794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 921,
          "minimum": 193.41,
          "maximum": 674.3562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 674.3562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 9-9.5MM 5400-031-xxx",
      "code_information": [
        {
          "code": "3002951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1113,
          "minimum": 233.73,
          "maximum": 814.9386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 814.9386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-TURBINATE INF SB2000SA",
      "code_information": [
        {
          "code": "3002962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1139,
          "minimum": 239.19,
          "maximum": 833.9758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 833.9758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SERRATED STND SB4000SS",
      "code_information": [
        {
          "code": "3002963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 951.86,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MYRINGOTOMY SPEAR TIP",
      "code_information": [
        {
          "code": "3003112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RAD 40 DEGREE 18-84006HR",
      "code_information": [
        {
          "code": "3003122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1727,
          "minimum": 362.67,
          "maximum": 1264.5094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1264.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RADNOID 18-84008",
      "code_information": [
        {
          "code": "3003123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1721,
          "minimum": 361.41,
          "maximum": 1260.1162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1260.1162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RASP SAW       510037113",
      "code_information": [
        {
          "code": "3003127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 811.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW MICR 9MM 2296-3-100s",
      "code_information": [
        {
          "code": "3003143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 381.4762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG SAW 9X25 ALL 2296s",
      "code_information": [
        {
          "code": "3003147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 381.4762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 5.5MMX18MM  KM 3-412",
      "code_information": [
        {
          "code": "3003150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW GIGLI ROUND  2808-01",
      "code_information": [
        {
          "code": "3003172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 234.304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HEX COATED 2.75   E1450X",
      "code_information": [
        {
          "code": "3003200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-INF TURB 2.0  18-82040HR",
      "code_information": [
        {
          "code": "3003227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2469,
          "minimum": 518.49,
          "maximum": 1807.8018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1807.8018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-STANDARD DISP   8000-140",
      "code_information": [
        {
          "code": "3003251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 167.6738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90Xxx    05.003.1xxS",
      "code_information": [
        {
          "code": "3003256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 456.8928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380HR",
      "code_information": [
        {
          "code": "3003258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1739,
          "minimum": 365.19,
          "maximum": 1273.2958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1273.2958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380EM",
      "code_information": [
        {
          "code": "3003259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2334.2536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS     519.xxxS",
      "code_information": [
        {
          "code": "3003292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 568.1872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CELL SAVER HI SP   CSP26x",
      "code_information": [
        {
          "code": "3003419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 777,
          "minimum": 163.17,
          "maximum": 568.9194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 568.9194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-SMARTMIX CTS    540176501",
      "code_information": [
        {
          "code": "3003433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-INTERNAL AR-1678-CP",
      "code_information": [
        {
          "code": "3003471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5500,
          "minimum": 1155,
          "maximum": 4027.1,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4027.1,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-UNIV X-ACT 11-2151-9",
      "code_information": [
        {
          "code": "3003472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 998,
          "minimum": 209.58,
          "maximum": 730.7356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 730.7356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-COLON CYTO        000110",
      "code_information": [
        {
          "code": "3003503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-WHISTLE CLEANING  000101",
      "code_information": [
        {
          "code": "3003605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 95.186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT RND 2296-100-421",
      "code_information": [
        {
          "code": "3003756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL CUTTING 5300-010-901",
      "code_information": [
        {
          "code": "3003762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 203.5516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND          277-10-423",
      "code_information": [
        {
          "code": "3003782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND CUT 2.4MM  5091-225",
      "code_information": [
        {
          "code": "3003786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 177.1924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT 1.6   277-10-xxx",
      "code_information": [
        {
          "code": "3003792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-WATERMELON      1607-2-35",
      "code_information": [
        {
          "code": "3003805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 456.8928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL   SP-7810",
      "code_information": [
        {
          "code": "3003812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 932.8228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 2MM 5820-013-0xx",
      "code_information": [
        {
          "code": "3003829",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 935.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND S03.000.009S",
      "code_information": [
        {
          "code": "3003841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 395.388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND 4.0MM    277-10-240",
      "code_information": [
        {
          "code": "3003855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 230.643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 5MM     5820-013-050",
      "code_information": [
        {
          "code": "3003856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING BLUE   FL-601-97B",
      "code_information": [
        {
          "code": "3003905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT STERILE MAS PLIF",
      "code_information": [
        {
          "code": "3003914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2088.9666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ARCH 6.5  80320",
      "code_information": [
        {
          "code": "3004042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 264.3242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO DBL 5MM PAL-505LL",
      "code_information": [
        {
          "code": "3004047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY PREMATURE",
      "code_information": [
        {
          "code": "3004048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY NEONATAL",
      "code_information": [
        {
          "code": "3004049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERPAY INFANT",
      "code_information": [
        {
          "code": "3004051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-308LS",
      "code_information": [
        {
          "code": "3004052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 541.828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CURVED 100MM 20G 10.0M",
      "code_information": [
        {
          "code": "3004190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX FEM TFA-022-25",
      "code_information": [
        {
          "code": "3004225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 445.9098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX       TFA02025",
      "code_information": [
        {
          "code": "3004226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 445.9098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 27FR 96370-027",
      "code_information": [
        {
          "code": "3004235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1777,
          "minimum": 373.17,
          "maximum": 1301.1194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1301.1194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-I-STAT CREATININE",
      "code_information": [
        {
          "code": "3004750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 22FR 30CC      266722",
      "code_information": [
        {
          "code": "3004837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.3252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TACKER DELIVERY OMS-TTS",
      "code_information": [
        {
          "code": "3005077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3218,
          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2356.2196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHLOANGIOGRAM   20018-010",
      "code_information": [
        {
          "code": "3005234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 613,
          "minimum": 128.73,
          "maximum": 448.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 448.8386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 24Fr 5CC 265724",
      "code_information": [
        {
          "code": "3005414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3WAY         73022L",
      "code_information": [
        {
          "code": "3005435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 127.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 34FR-46FR ALL",
      "code_information": [
        {
          "code": "3007230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 446.642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 36FR-46FR  TF36460",
      "code_information": [
        {
          "code": "3007235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 446.642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP         AA01",
      "code_information": [
        {
          "code": "3007600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 80.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-ACU-DISPO      DCFT2",
      "code_information": [
        {
          "code": "3007601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP,MULTI-PIN LG 390.004",
      "code_information": [
        {
          "code": "3008494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4727,
          "minimum": 992.67,
          "maximum": 3461.1094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3461.1094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-NV DSC & IN-LINE ACTIVATO",
      "code_information": [
        {
          "code": "3008690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LAPRA-TY ABS SUTURE XC200",
      "code_information": [
        {
          "code": "3008699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 777,
          "minimum": 163.17,
          "maximum": 568.9194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 568.9194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIPS-HEM-O-LOC         544230",
      "code_information": [
        {
          "code": "3008728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.8268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK XL       544250",
      "code_information": [
        {
          "code": "3008731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X3/8 XA6062",
      "code_information": [
        {
          "code": "3009659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 871,
          "minimum": 182.91,
          "maximum": 637.7462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 637.7462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR ACCU-FLO 82-1504",
      "code_information": [
        {
          "code": "3009774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 829.5826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONSTAVAC-CBC II    225-28-614",
      "code_information": [
        {
          "code": "3009792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1463,
          "minimum": 307.23,
          "maximum": 1071.2086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1071.2086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR BOVIE DISP 301538",
      "code_information": [
        {
          "code": "3009842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR HIGH   26176LD/10",
      "code_information": [
        {
          "code": "3009843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 205.016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNULATED",
      "code_information": [
        {
          "code": "3009845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1933,
          "minimum": 405.93,
          "maximum": 1415.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1415.3426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNUL 3.8MM",
      "code_information": [
        {
          "code": "3009850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1317.2278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-SILICONE RETRACTOR",
      "code_information": [
        {
          "code": "3009851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-DISPOSABLE ACTIVE DAC",
      "code_information": [
        {
          "code": "3009853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 208.677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-8 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 188.9076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 208.677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.8056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-30 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 272.3784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 428,
          "minimum": 89.88,
          "maximum": 313.3816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 313.3816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 343.4018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CORONARY PERF    30055",
      "code_information": [
        {
          "code": "3010039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.0734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MERCEDES     PAL-506LL",
      "code_information": [
        {
          "code": "3010053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS ALL SZS   681xx",
      "code_information": [
        {
          "code": "3010076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 551,
          "minimum": 115.71,
          "maximum": 403.4422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 403.4422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT ALL SZ",
      "code_information": [
        {
          "code": "3010079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL 1X4  2111-04-077",
      "code_information": [
        {
          "code": "3010088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2712,
          "minimum": 569.52,
          "maximum": 1985.7264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1985.7264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL ALL  2111-08-07x",
      "code_information": [
        {
          "code": "3010090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5695,
          "minimum": 1195.95,
          "maximum": 4169.879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4169.879,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X20 657320",
      "code_information": [
        {
          "code": "3010104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 997.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X40 657340",
      "code_information": [
        {
          "code": "3010107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 997.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DUBIN              8390",
      "code_information": [
        {
          "code": "3010215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION         BID30",
      "code_information": [
        {
          "code": "3010259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 890,
          "minimum": 186.9,
          "maximum": 651.658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 651.658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE LITE 30-403LITE",
      "code_information": [
        {
          "code": "3010311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3419,
          "minimum": 717.99,
          "maximum": 2503.3918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2503.3918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LAPARSCOP PLUME FILTER",
      "code_information": [
        {
          "code": "3010330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 144.9756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VAGINAL POSITIONING",
      "code_information": [
        {
          "code": "3010598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2367,
          "minimum": 497.07,
          "maximum": 1733.1174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1733.1174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-BLUNT TIP 5 PK BTD05",
      "code_information": [
        {
          "code": "3010867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1 5901-1126",
      "code_information": [
        {
          "code": "3011002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHAN W/TROCAR ALL SIZES",
      "code_information": [
        {
          "code": "3011730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 199,
          "minimum": 41.79,
          "maximum": 145.7078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 145.7078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT HUBLESS ALL SZS",
      "code_information": [
        {
          "code": "3011780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.1116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-MINI CHEST 500     16400",
      "code_information": [
        {
          "code": "3011787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1139,
          "minimum": 239.19,
          "maximum": 833.9758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 833.9758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FECAL MANAGEMENT 418000",
      "code_information": [
        {
          "code": "3011910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1469,
          "minimum": 308.49,
          "maximum": 1075.6018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1075.6018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FECAL MANAGEMENT 411108",
      "code_information": [
        {
          "code": "3011911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-HIP W/POUCHES DYNJP8201",
      "code_information": [
        {
          "code": "3011920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 158.8874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BEACH CHAIR SHOULDER",
      "code_information": [
        {
          "code": "3011922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 257,
          "minimum": 53.97,
          "maximum": 188.1754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 188.1754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BARIATRIC      DYNJP3105",
      "code_information": [
        {
          "code": "3011926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 166.9416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-DOUBLE 44X66     ORS 320",
      "code_information": [
        {
          "code": "3011927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 357.3136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 12MM CD004",
      "code_information": [
        {
          "code": "3011949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE 3M SHORT   6661EZ",
      "code_information": [
        {
          "code": "3011953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-ISO IOBAN HIP       6617",
      "code_information": [
        {
          "code": "3011959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 195.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INTESTINAL 18X18.5 ISO1003",
      "code_information": [
        {
          "code": "3011960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 360,
          "minimum": 75.6,
          "maximum": 263.592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 263.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 10MM CD001",
      "code_information": [
        {
          "code": "3011961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI     326088-0000-000",
      "code_information": [
        {
          "code": "3011985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI FULL         306070",
      "code_information": [
        {
          "code": "3011987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 279,
          "minimum": 58.59,
          "maximum": 204.2838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 204.2838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER           ORS-400",
      "code_information": [
        {
          "code": "3011995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 432.7302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERI IRRIGATION    1016",
      "code_information": [
        {
          "code": "3012018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE HAND   DYNJP8005",
      "code_information": [
        {
          "code": "3012025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.7928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GENTLE CARE SURG 12-1",
      "code_information": [
        {
          "code": "3012060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 480,
          "minimum": 100.8,
          "maximum": 351.456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 351.456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-TOPIFOAM      5710-30",
      "code_information": [
        {
          "code": "3012080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN TWIST 2.7MM W/AO F",
      "code_information": [
        {
          "code": "3012109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2077,
          "minimum": 436.17,
          "maximum": 1520.7794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1520.7794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.0MM ASNIS",
      "code_information": [
        {
          "code": "3012113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1913,
          "minimum": 401.73,
          "maximum": 1400.6986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1400.6986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-HEX 1.1X67       15-1723",
      "code_information": [
        {
          "code": "3012115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1211,
          "minimum": 254.31,
          "maximum": 886.6942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 886.6942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3012118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN 4.0MM W/AO",
      "code_information": [
        {
          "code": "3012152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5392,
          "minimum": 1132.32,
          "maximum": 3948.0224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3948.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SHAFT-AO 2.6MMX122MM",
      "code_information": [
        {
          "code": "3012186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1070.4764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           310.48",
      "code_information": [
        {
          "code": "3012201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1176,
          "minimum": 246.96,
          "maximum": 861.0672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 861.0672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO SMALL  1320-3042S",
      "code_information": [
        {
          "code": "3012204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1181,
          "minimum": 248.01,
          "maximum": 864.7282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 864.7282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1806-5010S",
      "code_information": [
        {
          "code": "3012206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1103,
          "minimum": 231.63,
          "maximum": 807.6166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 807.6166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 03.6MMX122MM",
      "code_information": [
        {
          "code": "3012207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1378,
          "minimum": 289.38,
          "maximum": 1008.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1008.9716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM       60-19326",
      "code_information": [
        {
          "code": "3012208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 814.2064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 13.0MM CANNULATED",
      "code_information": [
        {
          "code": "3012314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4464,
          "minimum": 937.44,
          "maximum": 3268.5408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3268.5408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0           310.21",
      "code_information": [
        {
          "code": "3012318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 711.6984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         MS-DCR20",
      "code_information": [
        {
          "code": "3012321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 LG 120MM",
      "code_information": [
        {
          "code": "3012325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1725,
          "minimum": 362.25,
          "maximum": 1263.045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1263.045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 315.28",
      "code_information": [
        {
          "code": "3012330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1374,
          "minimum": 288.54,
          "maximum": 1006.0428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1006.0428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8          310.288",
      "code_information": [
        {
          "code": "3012331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2           405883",
      "code_information": [
        {
          "code": "3012341",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1098,
          "minimum": 230.58,
          "maximum": 803.9556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.9556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X40   2274-12-000",
      "code_information": [
        {
          "code": "3012344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1940,
          "minimum": 407.4,
          "maximum": 1420.468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1420.468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5          MS-DC35",
      "code_information": [
        {
          "code": "3012346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1055,
          "minimum": 221.55,
          "maximum": 772.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 772.471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.201",
      "code_information": [
        {
          "code": "3012355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 912,
          "minimum": 191.52,
          "maximum": 667.7664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 667.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL               310.28",
      "code_information": [
        {
          "code": "3012356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 711.6984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.431",
      "code_information": [
        {
          "code": "3012357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1411,
          "minimum": 296.31,
          "maximum": 1033.1342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1033.1342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL            32-486265",
      "code_information": [
        {
          "code": "3012365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 769,
          "minimum": 161.49,
          "maximum": 563.0618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 563.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL         5820-107-530",
      "code_information": [
        {
          "code": "3012374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           AT2M-L1813",
      "code_information": [
        {
          "code": "3012378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2410,
          "minimum": 506.1,
          "maximum": 1764.602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1764.602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED   310.634",
      "code_information": [
        {
          "code": "3012380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1957.1706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 5.0MM",
      "code_information": [
        {
          "code": "3012381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1957.1706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM 60-19340",
      "code_information": [
        {
          "code": "3012401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 806.8844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHRT 3.2 03.010.103S",
      "code_information": [
        {
          "code": "3012406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1666,
          "minimum": 349.86,
          "maximum": 1219.8452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1219.8452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL LOOP      B0512",
      "code_information": [
        {
          "code": "3012465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 272.3784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X2.75 E1455",
      "code_information": [
        {
          "code": "3012472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X4  E1455-4",
      "code_information": [
        {
          "code": "3012473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.9352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-208",
      "code_information": [
        {
          "code": "3012474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1372,
          "minimum": 288.12,
          "maximum": 1004.5784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1004.5784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EZ CLEAN CAUTERY TIP",
      "code_information": [
        {
          "code": "3012505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 39.5388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE MOD     0014AM",
      "code_information": [
        {
          "code": "3012507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.1116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK  E2773-45",
      "code_information": [
        {
          "code": "3012520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 305.3274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MRI CONDITIONAL DISP",
      "code_information": [
        {
          "code": "3012521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LIGASURE      LS1037",
      "code_information": [
        {
          "code": "3012535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2512,
          "minimum": 527.52,
          "maximum": 1839.2864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1839.2864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 2CHAN 8227410",
      "code_information": [
        {
          "code": "3012585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1545,
          "minimum": 324.45,
          "maximum": 1131.249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1131.249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-MEDISPEC        SE-1",
      "code_information": [
        {
          "code": "3012590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 401.9778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-RADIUS LOOP    R1010",
      "code_information": [
        {
          "code": "3012596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 272.3784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 6.5\\\" 0014M",
      "code_information": [
        {
          "code": "3012611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-TEFLON 6 1/2 BLADE",
      "code_information": [
        {
          "code": "3012613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.6472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDCAP-ROUND X-CORE    5960200",
      "code_information": [
        {
          "code": "3012635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4702,
          "minimum": 987.42,
          "maximum": 3442.8044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3442.8044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3012680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2877,
          "minimum": 604.17,
          "maximum": 2106.5394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2106.5394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVACUATOR-UROVAC       730-125",
      "code_information": [
        {
          "code": "3012699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.0734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVAC-SAF-T-VAC         ST9000S",
      "code_information": [
        {
          "code": "3012723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-GLUE             540133500",
      "code_information": [
        {
          "code": "3012805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXCISOR-BIOPSY CONE",
      "code_information": [
        {
          "code": "3012815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-DIALYSIS CATH  415612",
      "code_information": [
        {
          "code": "3012854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1265,
          "minimum": 265.65,
          "maximum": 926.233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 926.233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTRACTOR-TRIGEN DISP 71631320",
      "code_information": [
        {
          "code": "3012895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 956.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBE-VIPERSLIDE VPR-SLD2",
      "code_information": [
        {
          "code": "3012925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 1X6        007976",
      "code_information": [
        {
          "code": "3012991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 710.9662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 4\\\"X4\\\"       007836",
      "code_information": [
        {
          "code": "3012993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2074,
          "minimum": 435.54,
          "maximum": 1518.5828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1518.5828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 200M",
      "code_information": [
        {
          "code": "3013060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2420,
          "minimum": 508.2,
          "maximum": 1771.924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1771.924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 365M",
      "code_information": [
        {
          "code": "3013061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2010,
          "minimum": 422.1,
          "maximum": 1471.722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1471.722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 550M",
      "code_information": [
        {
          "code": "3013062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2649,
          "minimum": 556.29,
          "maximum": 1939.5978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1939.5978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 1000M",
      "code_information": [
        {
          "code": "3013063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3743,
          "minimum": 786.03,
          "maximum": 2740.6246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2740.6246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-COUDE HEYMAN   021300",
      "code_information": [
        {
          "code": "3013087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1917,
          "minimum": 402.57,
          "maximum": 1403.6274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1403.6274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-HEYMAN         021100",
      "code_information": [
        {
          "code": "3013090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1718,
          "minimum": 360.78,
          "maximum": 1257.9196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1257.9196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPER-          AR-7237-7",
      "code_information": [
        {
          "code": "3013107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 3  AR-7227-01",
      "code_information": [
        {
          "code": "3013134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 240.8938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 4  AR-7230-01",
      "code_information": [
        {
          "code": "3013135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 264.3242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-HEPA BACTERIA 00182",
      "code_information": [
        {
          "code": "3013160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.1116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PED OXYKID W/7' TUBING",
      "code_information": [
        {
          "code": "3013161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-INSUFFLATION BULB",
      "code_information": [
        {
          "code": "3013164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP     1599-05",
      "code_information": [
        {
          "code": "3013203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 237,
          "minimum": 49.77,
          "maximum": 173.5314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 173.5314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-PIRANHA 3FR     505-160",
      "code_information": [
        {
          "code": "3013317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2055,
          "minimum": 431.55,
          "maximum": 1504.671,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1504.671,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW      000300s",
      "code_information": [
        {
          "code": "3013320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RJ4 LC BIOPSY 160CM",
      "code_information": [
        {
          "code": "3013323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GEL-PROLARYN          8602M0K5",
      "code_information": [
        {
          "code": "3013462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4034,
          "minimum": 847.14,
          "maximum": 2953.6948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2953.6948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3014234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 6.5 DRILL",
      "code_information": [
        {
          "code": "3014235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 955.521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-AR-8737-01",
      "code_information": [
        {
          "code": "3014239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3014272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 112.7588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-DBX MIX 2.5CC     058025",
      "code_information": [
        {
          "code": "3014900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2432,
          "minimum": 510.72,
          "maximum": 1780.7104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1780.7104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-WIRE .035      WS-0906ST",
      "code_information": [
        {
          "code": "3016121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.0468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2MM           292.65",
      "code_information": [
        {
          "code": "3016129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 552,
          "minimum": 115.92,
          "maximum": 404.1744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 404.1744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0MM 702460",
      "code_information": [
        {
          "code": "3016131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K SMOOTH TIP AGK16100",
      "code_information": [
        {
          "code": "3016134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-3.2       03.010.115",
      "code_information": [
        {
          "code": "3016135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1091,
          "minimum": 229.11,
          "maximum": 798.8302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 798.8302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K W/OLIVE STOP",
      "code_information": [
        {
          "code": "3016136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1032.402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-SUT GABBY-FRATER SUT 013",
      "code_information": [
        {
          "code": "3016153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 205.016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDETHREAD 150MM  292.72",
      "code_information": [
        {
          "code": "3016158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 461,
          "minimum": 96.81,
          "maximum": 337.5442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 337.5442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP AR894301",
      "code_information": [
        {
          "code": "3016164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-HALTER DISP 08143101",
      "code_information": [
        {
          "code": "3016272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 118,
          "minimum": 24.78,
          "maximum": 86.3996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 86.3996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ADHESIVE 4\\\" WHITE",
      "code_information": [
        {
          "code": "3016326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1963",
      "code_information": [
        {
          "code": "3016347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1292,
          "minimum": 271.32,
          "maximum": 946.0024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 946.0024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOVAC-400ML LG   2550-004-10",
      "code_information": [
        {
          "code": "3016381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.8332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-HYDRODEB     1914001",
      "code_information": [
        {
          "code": "3016387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2186,
          "minimum": 459.06,
          "maximum": 1600.5892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1600.5892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM DOUBLE  3384-4",
      "code_information": [
        {
          "code": "3016425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 434,
          "minimum": 91.14,
          "maximum": 317.7748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 317.7748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 4X4 2083",
      "code_information": [
        {
          "code": "3016451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1255,
          "minimum": 263.55,
          "maximum": 918.911,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 918.911,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-J CAUTERY     60-5272-232",
      "code_information": [
        {
          "code": "3016500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 200.6228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-ULTRASLING III XLG",
      "code_information": [
        {
          "code": "3017486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 316.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUTTLE-ACCU PASS SUTURE 70DEG",
      "code_information": [
        {
          "code": "3019705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1334,
          "minimum": 280.14,
          "maximum": 976.7548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 976.7548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-EVERGRIP LF  EVERGRIP61",
      "code_information": [
        {
          "code": "3019748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.7684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FDG",
      "code_information": [
        {
          "code": "3019810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2674,
          "minimum": 561.54,
          "maximum": 1957.9028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1957.9028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGL",
      "code_information": [
        {
          "code": "3019813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2674,
          "minimum": 561.54,
          "maximum": 1957.9028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1957.9028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGD",
      "code_information": [
        {
          "code": "3019815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3010,
          "minimum": 632.1,
          "maximum": 2203.922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2203.922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-PEELAWAY 16F",
      "code_information": [
        {
          "code": "3019878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 615,
          "minimum": 129.15,
          "maximum": 450.303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 450.303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT 9FR 3 1/2 PI93",
      "code_information": [
        {
          "code": "3019879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 381,
          "minimum": 80.01,
          "maximum": 278.9682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 278.9682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP NICU HNICU37",
      "code_information": [
        {
          "code": "3019903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2MM 500373",
      "code_information": [
        {
          "code": "3020202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 709,
          "minimum": 148.89,
          "maximum": 519.1298,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 519.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPER DISTRACTOR FF904SB",
      "code_information": [
        {
          "code": "3020203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1060,
          "minimum": 222.6,
          "maximum": 776.132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 776.132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 17L 96550",
      "code_information": [
        {
          "code": "3020800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 515,
          "minimum": 108.15,
          "maximum": 377.083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 377.083,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-I RING PUPIL 587000",
      "code_information": [
        {
          "code": "3020804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1251,
          "minimum": 262.71,
          "maximum": 915.9822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 915.9822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL VISULIZATION",
      "code_information": [
        {
          "code": "3020806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUG 03.804.522S",
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        {
          "code": "3020807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 859,
          "minimum": 180.39,
          "maximum": 628.9598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 628.9598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SCOPE WARMER TM500",
      "code_information": [
        {
          "code": "3020808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENTI SCAN IV DISP 177-092",
      "code_information": [
        {
          "code": "3020810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 451,
          "minimum": 94.71,
          "maximum": 330.2222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 330.2222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESSORY 700     72401850",
      "code_information": [
        {
          "code": "3020811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5472,
          "minimum": 1149.12,
          "maximum": 4006.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4006.5984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COAG  CSP208",
      "code_information": [
        {
          "code": "3020850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DILATOR NVM5       2029950",
      "code_information": [
        {
          "code": "3020915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3510.899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-19",
      "code_information": [
        {
          "code": "3020920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 997.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-21",
      "code_information": [
        {
          "code": "3020922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2245,
          "minimum": 471.45,
          "maximum": 1643.789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1643.789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC     96530-017",
      "code_information": [
        {
          "code": "3020928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 861.7994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IV MAXCESS         3240060",
      "code_information": [
        {
          "code": "3020969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8227,
          "minimum": 1727.67,
          "maximum": 6023.8094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 6023.8094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX PT STARTER  50-0071",
      "code_information": [
        {
          "code": "3021029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1676.0058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHUNT NONINVASIVE  9733605",
      "code_information": [
        {
          "code": "3021032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3599,
          "minimum": 755.79,
          "maximum": 2635.1878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2635.1878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 4ML 1501262",
      "code_information": [
        {
          "code": "3021034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1178.842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH&BOOT 3550-80",
      "code_information": [
        {
          "code": "3021046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 476,
          "minimum": 99.96,
          "maximum": 348.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 348.5272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERITONEAL DIALYSIS 278006",
      "code_information": [
        {
          "code": "3021065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 842.03,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHOULDER CANNULA 5CM  9718",
      "code_information": [
        {
          "code": "3021080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 126.6706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-URO MAX HI PRESURE 225-136",
      "code_information": [
        {
          "code": "3021090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1753,
          "minimum": 368.13,
          "maximum": 1283.5466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1283.5466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXTRACTION GTG14",
      "code_information": [
        {
          "code": "3021113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4570,
          "minimum": 959.7,
          "maximum": 3346.154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3346.154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X12MM 663812",
      "code_information": [
        {
          "code": "3021130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 951,
          "minimum": 199.71,
          "maximum": 696.3222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 696.3222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-CRESCENT         74-1010",
      "code_information": [
        {
          "code": "3021150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 88.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE,SLIT 2.4MM 45 DEGREE",
      "code_information": [
        {
          "code": "3021161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 192.5686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-GRAFT ACL 10MM    232110",
      "code_information": [
        {
          "code": "3021173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2004,
          "minimum": 420.84,
          "maximum": 1467.3288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1467.3288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT CLEAR CUT 2.4",
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        {
          "code": "3021199",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 357.3136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDE PORT 1.1    78-2010",
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        {
          "code": "3021203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-TUIP             880-217",
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        {
          "code": "3021220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 749,
          "minimum": 157.29,
          "maximum": 548.4178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 548.4178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE ALL AR-4000Ss",
      "code_information": [
        {
          "code": "3021225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE         AR-4068's",
      "code_information": [
        {
          "code": "3021227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1070.4764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDEPORT SAFETY 1.0MM",
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        {
          "code": "3021241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 237.2328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINER-SZ25/36MM RL 12-105995",
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        {
          "code": "3021635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4400,
          "minimum": 924,
          "maximum": 3221.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3221.68,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-IMPACT         LF4318",
      "code_information": [
        {
          "code": "3021733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2708,
          "minimum": 568.68,
          "maximum": 1982.7976,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1982.7976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-DRAINAGE LOCKABLE 50-7245",
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        {
          "code": "3021737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 191.1042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 26FR      880-214",
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        {
          "code": "3021821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 508.1468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-DISPOSA ALL",
      "code_information": [
        {
          "code": "3021826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 176.4602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-ELECTRODE 24FR   WA22037C",
      "code_information": [
        {
          "code": "3021880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1483,
          "minimum": 311.43,
          "maximum": 1085.8526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1085.8526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WIRE SNARE 8-14515",
      "code_information": [
        {
          "code": "3021881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 429.8014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-MS SSEP NEEDLE  8050315",
      "code_information": [
        {
          "code": "3022945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5246,
          "minimum": 1101.66,
          "maximum": 3841.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3841.1212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE MEP/EMG",
      "code_information": [
        {
          "code": "3022955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3717.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SINGLE PORT PAL 240LS",
      "code_information": [
        {
          "code": "3023177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 582.8312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY STEALTH  9733068",
      "code_information": [
        {
          "code": "3027284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4784,
          "minimum": 1004.64,
          "maximum": 3502.8448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3502.8448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY TRU CUT 2N2700s",
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        {
          "code": "3027285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 155.2264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY CUT      4418-16",
      "code_information": [
        {
          "code": "3027295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DEFLUX 23GX3.7FX350mm",
      "code_information": [
        {
          "code": "3027296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 744,
          "minimum": 156.24,
          "maximum": 544.7568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 544.7568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DISP INSUF      S100000",
      "code_information": [
        {
          "code": "3027310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 482,
          "minimum": 101.22,
          "maximum": 352.9204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 352.9204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ELECTRODE COATD E1465-6",
      "code_information": [
        {
          "code": "3027313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ENDOPATH INSUFF   PN120",
      "code_information": [
        {
          "code": "3027315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 719,
          "minimum": 150.99,
          "maximum": 526.4518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 526.4518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL       105-1314",
      "code_information": [
        {
          "code": "3027318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-20      G00013",
      "code_information": [
        {
          "code": "3027330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FORAMEN 20G      041829",
      "code_information": [
        {
          "code": "3027344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 303.863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-6 DJ6011X",
      "code_information": [
        {
          "code": "3027346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 292,
          "minimum": 61.32,
          "maximum": 213.8024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 213.8024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR        1650050",
      "code_information": [
        {
          "code": "3027347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 390,
          "minimum": 81.9,
          "maximum": 285.558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 285.558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSULATED EDGE   E1465B",
      "code_information": [
        {
          "code": "3027368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 165.4772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TR-CRON 2-0 STR W/10 SW",
      "code_information": [
        {
          "code": "3027402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 319.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR W/SHEATH",
      "code_information": [
        {
          "code": "3027403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 626,
          "minimum": 131.46,
          "maximum": 458.3572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 458.3572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OPUS SPEEDSTITCH",
      "code_information": [
        {
          "code": "3027425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 397,
          "minimum": 83.37,
          "maximum": 290.6834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 290.6834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OCTRODE 6\\\"         1116",
      "code_information": [
        {
          "code": "3027430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION      AR-13991N",
      "code_information": [
        {
          "code": "3027443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1070.4764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SIDEKICK 21GA 14.6\\\"",
      "code_information": [
        {
          "code": "3027445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 793,
          "minimum": 166.53,
          "maximum": 580.6346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 580.6346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODISSECTION   E1xxx",
      "code_information": [
        {
          "code": "3027520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 795,
          "minimum": 166.95,
          "maximum": 582.099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 582.099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-W/BASEPLATE BSDN-18-7.0",
      "code_information": [
        {
          "code": "3027587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 5MM  VS101005",
      "code_information": [
        {
          "code": "3027591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1299,
          "minimum": 272.79,
          "maximum": 951.1278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 951.1278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VERSASTEP 14GA VS150000",
      "code_information": [
        {
          "code": "3027593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 600,
          "minimum": 126,
          "maximum": 439.32,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 439.32,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TROCAR 12MM VS101000s",
      "code_information": [
        {
          "code": "3027595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1224,
          "minimum": 257.04,
          "maximum": 896.2128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 896.2128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-WILSON PENILE IMPLANT",
      "code_information": [
        {
          "code": "3029175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2504,
          "minimum": 525.84,
          "maximum": 1833.4288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1833.4288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FENWAL TRANSFER 4R2014",
      "code_information": [
        {
          "code": "3029199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAGNETIC DRAPE    31140562",
      "code_information": [
        {
          "code": "3029201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY ELITE VIAL     LC3001",
      "code_information": [
        {
          "code": "3029202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3536,
          "minimum": 742.56,
          "maximum": 2589.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2589.0592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SENSA TRAC M8275057/10",
      "code_information": [
        {
          "code": "3029214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-PERFUSION CUSTOM  CK0226R",
      "code_information": [
        {
          "code": "3029252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3994,
          "minimum": 838.74,
          "maximum": 2924.4068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2924.4068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SHOULDER ARTHROSCOP 29367",
      "code_information": [
        {
          "code": "3029266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 191.1042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SINUS KENNEDY      400422",
      "code_information": [
        {
          "code": "3029267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-TOTAL JOINT    DYNJ31778A",
      "code_information": [
        {
          "code": "3029268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 863.996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM     440400",
      "code_information": [
        {
          "code": "3029278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VITRECTOMY CENTURION",
      "code_information": [
        {
          "code": "3029308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH  82-151x",
      "code_information": [
        {
          "code": "3029345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1307,
          "minimum": 274.47,
          "maximum": 956.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 956.9854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SMART STITCH PERFECT",
      "code_information": [
        {
          "code": "3029347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 917,
          "minimum": 192.57,
          "maximum": 671.4274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 671.4274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE           032401",
      "code_information": [
        {
          "code": "3029348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE LF 022701",
      "code_information": [
        {
          "code": "3029356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 713,
          "minimum": 149.73,
          "maximum": 522.0586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 522.0586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-HEMA KNITTED   HGK75/75P",
      "code_information": [
        {
          "code": "3029426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1254,
          "minimum": 263.34,
          "maximum": 918.1788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 918.1788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-ACTIVA 2.5 INTELLIDOSE",
      "code_information": [
        {
          "code": "3029528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-DISPOSABLE  26-1221",
      "code_information": [
        {
          "code": "3029529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1960.8316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORIENTATION 2307-71-000",
      "code_information": [
        {
          "code": "3029762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 727.8068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-NAVIGATION 6007-003-150",
      "code_information": [
        {
          "code": "3029767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 684.607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ARM ELEVATION 79-90500",
      "code_information": [
        {
          "code": "3029771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KNEE PROCEDURE TRACK 10712",
      "code_information": [
        {
          "code": "3029811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 997.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-DEMAYO LEG 110550",
      "code_information": [
        {
          "code": "3029813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BREAKAWAY GUIDE 2.5MM",
      "code_information": [
        {
          "code": "3029840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2605,
          "minimum": 547.05,
          "maximum": 1907.381,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1907.381,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144110",
      "code_information": [
        {
          "code": "3029841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1086,
          "minimum": 228.06,
          "maximum": 795.1692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 795.1692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DHS GUIDE          900.723",
      "code_information": [
        {
          "code": "3029855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 658,
          "minimum": 138.18,
          "maximum": 481.7876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.7876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-POSITIONING EZ CLIP 2MM",
      "code_information": [
        {
          "code": "3029858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 822.2606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-FLUTED HEADLESS 7650-2038A",
      "code_information": [
        {
          "code": "3029885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1881,
          "minimum": 395.01,
          "maximum": 1377.2682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1377.2682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE              357.399",
      "code_information": [
        {
          "code": "3029929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1109,
          "minimum": 232.89,
          "maximum": 812.0098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 812.0098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PINS-GUIDE 7.3         900.726",
      "code_information": [
        {
          "code": "3030050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 943,
          "minimum": 198.03,
          "maximum": 690.4646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 690.4646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z463G",
      "code_information": [
        {
          "code": "3032618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1\\\"",
      "code_information": [
        {
          "code": "3033301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 48,
          "minimum": 10.08,
          "maximum": 35.1456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 35.1456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 16FR 10ML",
      "code_information": [
        {
          "code": "3033303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F SCREWS 45-80040",
      "code_information": [
        {
          "code": "3033883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1070.4764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-LARGE SOFT       PCP40",
      "code_information": [
        {
          "code": "3033952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POINTER-TRACER         9733423",
      "code_information": [
        {
          "code": "3034140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3396,
          "minimum": 713.16,
          "maximum": 2486.5512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2486.5512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-BIOPSY             AUR-BP",
      "code_information": [
        {
          "code": "3034190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 316,
          "minimum": 66.36,
          "maximum": 231.3752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 231.3752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-GEL HAND            C8XX2",
      "code_information": [
        {
          "code": "3034194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2891.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOCATCH-II W/POUCH ALL 173's",
      "code_information": [
        {
          "code": "3034302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2140,
          "minimum": 449.4,
          "maximum": 1566.908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1566.908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD ENTERAL 7FR 350CM",
      "code_information": [
        {
          "code": "3034510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NEUROVISION M5   2012021",
      "code_information": [
        {
          "code": "3034522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PIGTAIL 28-0174",
      "code_information": [
        {
          "code": "3034526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 779.793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LAPAROSCOPIC 5MM  160655",
      "code_information": [
        {
          "code": "3034572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 842.7622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 2.3MM 6.9FR 300CM",
      "code_information": [
        {
          "code": "3034891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-WOUND GELPOINT CNGL2",
      "code_information": [
        {
          "code": "3038330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3097.9382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-PAIN ONQ 400ML    PM028-A",
      "code_information": [
        {
          "code": "3038635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1884,
          "minimum": 395.64,
          "maximum": 1379.4648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1379.4648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-KNOT 2-0 FIBERWIRE",
      "code_information": [
        {
          "code": "3038667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 955.521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-DEKNATEL 4.4      MDP-44",
      "code_information": [
        {
          "code": "3038930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 398,
          "minimum": 83.58,
          "maximum": 291.4156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 291.4156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GREEN    ECR45G",
      "code_information": [
        {
          "code": "3039881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1406,
          "minimum": 295.26,
          "maximum": 1029.4732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1029.4732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO LINEAR       TR35B",
      "code_information": [
        {
          "code": "3039888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 838,
          "minimum": 175.98,
          "maximum": 613.5836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 613.5836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-TUBING         RF10210",
      "code_information": [
        {
          "code": "3039889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W564",
      "code_information": [
        {
          "code": "3039894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 105.4368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W332",
      "code_information": [
        {
          "code": "3039896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 105.4368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN        XR30G",
      "code_information": [
        {
          "code": "3039899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 315.5782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH       170056",
      "code_information": [
        {
          "code": "3039902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 631.1564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-VASCULAR/THIN     TR45W",
      "code_information": [
        {
          "code": "3039909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 890.3552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM              XR30B",
      "code_information": [
        {
          "code": "3039911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 315.5782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STANDARD BLUE     6R45B",
      "code_information": [
        {
          "code": "3039912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1216,
          "minimum": 255.36,
          "maximum": 890.3552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 890.3552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40B",
      "code_information": [
        {
          "code": "3039913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1699,
          "minimum": 356.79,
          "maximum": 1244.0078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1244.0078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD- STAPLE TCR-55",
      "code_information": [
        {
          "code": "3039914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 499,
          "minimum": 104.79,
          "maximum": 365.3678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 365.3678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-LINEAR CUTTER    TCR-75",
      "code_information": [
        {
          "code": "3039916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 820,
          "minimum": 172.2,
          "maximum": 600.404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 600.404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40G",
      "code_information": [
        {
          "code": "3039917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1699,
          "minimum": 356.79,
          "maximum": 1244.0078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1244.0078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER    TCT75",
      "code_information": [
        {
          "code": "3039918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1465,
          "minimum": 307.65,
          "maximum": 1072.673,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1072.673,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM BLUE         XR60B",
      "code_information": [
        {
          "code": "3039920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 514,
          "minimum": 107.94,
          "maximum": 376.3508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 376.3508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO GIA 30/3.5  030452",
      "code_information": [
        {
          "code": "3039932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2061,
          "minimum": 432.81,
          "maximum": 1509.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1509.0642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-CARIOTOMY        205",
      "code_information": [
        {
          "code": "3039975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 465,
          "minimum": 97.65,
          "maximum": 340.473,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 340.473,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-DISP FILTRA 04259",
      "code_information": [
        {
          "code": "3039981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 428.337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-OMMAYA    NL850-121x",
      "code_information": [
        {
          "code": "3040439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3043,
          "minimum": 639.03,
          "maximum": 2228.0846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2228.0846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD UNIV     050602",
      "code_information": [
        {
          "code": "3040461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 224.0532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-C-SECTION DISP G6314",
      "code_information": [
        {
          "code": "3040500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 603.3328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND          C8404",
      "code_information": [
        {
          "code": "3040501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 603.3328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEXOR TENDON",
      "code_information": [
        {
          "code": "3040509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1960.8316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-LONESTAR        3304",
      "code_information": [
        {
          "code": "3040511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1080,
          "minimum": 226.8,
          "maximum": 790.776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 790.776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ORTHO ALEXIS   HR004",
      "code_information": [
        {
          "code": "3040513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1611,
          "minimum": 338.31,
          "maximum": 1179.5742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1179.5742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE        013593",
      "code_information": [
        {
          "code": "3040518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 558,
          "minimum": 117.18,
          "maximum": 408.5676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 408.5676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-SURGICAL RING   3715",
      "code_information": [
        {
          "code": "3040521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1370,
          "minimum": 287.7,
          "maximum": 1003.114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1003.114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-LOOPED 3 PRONG  5030",
      "code_information": [
        {
          "code": "3040525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 546.9534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND LG       C8303",
      "code_information": [
        {
          "code": "3040527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND MEDIUM   C8302",
      "code_information": [
        {
          "code": "3040530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XL       C8304",
      "code_information": [
        {
          "code": "3040532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 603.3328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND SMALL    C8301",
      "code_information": [
        {
          "code": "3040533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XSMALL   C8312",
      "code_information": [
        {
          "code": "3040534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-MALYUGIN ALL SZS MAL-000x",
      "code_information": [
        {
          "code": "3040661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1565,
          "minimum": 328.65,
          "maximum": 1145.893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1145.893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.8 CANN DRI",
      "code_information": [
        {
          "code": "3040704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1253.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-2.0X7          AR-7200S",
      "code_information": [
        {
          "code": "3044850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 605.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 2.3 BIPOLAR",
      "code_information": [
        {
          "code": "3044897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2039.177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS MALLEABLE BI",
      "code_information": [
        {
          "code": "3044899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3215,
          "minimum": 675.15,
          "maximum": 2354.023,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2354.023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION ANSPACH 111613",
      "code_information": [
        {
          "code": "3044922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 707.3052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCISSORS-ENDODUT METZ     3142",
      "code_information": [
        {
          "code": "3044930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 460,
          "minimum": 96.6,
          "maximum": 336.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 336.812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68HP ALL",
      "code_information": [
        {
          "code": "3049715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY ALL 351-3000'sS",
      "code_information": [
        {
          "code": "3049750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRI PORT III PAL 303LS",
      "code_information": [
        {
          "code": "3050004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 4.0X170 144170",
      "code_information": [
        {
          "code": "3050009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 691.929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CELLEBRITY CYTOLOGY",
      "code_information": [
        {
          "code": "3050015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 234,
          "minimum": 49.14,
          "maximum": 171.3348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 171.3348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATIR SM DISP 13MM",
      "code_information": [
        {
          "code": "3055843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 144.2434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 2ML 1506078",
      "code_information": [
        {
          "code": "3055845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1499,
          "minimum": 314.79,
          "maximum": 1097.5678,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1097.5678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL ALL SZS 456.30Xs",
      "code_information": [
        {
          "code": "3055898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3677,
          "minimum": 772.17,
          "maximum": 2692.2994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2692.2994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MISTY NEB W/FILTER",
      "code_information": [
        {
          "code": "3058511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-HELIOCOIDAL RASP 3.2MM",
      "code_information": [
        {
          "code": "3058512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1092,
          "minimum": 229.32,
          "maximum": 799.5624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 799.5624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONE MILL DISP",
      "code_information": [
        {
          "code": "3058513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1791,
          "minimum": 376.11,
          "maximum": 1311.3702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1311.3702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-CORE IRRIGATION",
      "code_information": [
        {
          "code": "3058514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 472,
          "minimum": 99.12,
          "maximum": 345.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 345.5984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 2.3MM",
      "code_information": [
        {
          "code": "3058515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1089,
          "minimum": 228.69,
          "maximum": 797.3658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 797.3658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-SOFT TOUCH RND FLUTED ALL",
      "code_information": [
        {
          "code": "3058516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND ALL SIZES",
      "code_information": [
        {
          "code": "3058517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 935.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND COURSE ALL",
      "code_information": [
        {
          "code": "3058518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 3.0MM",
      "code_information": [
        {
          "code": "3058521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1089,
          "minimum": 228.69,
          "maximum": 797.3658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 797.3658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CUTTING DIAMOND 25.4X0.8",
      "code_information": [
        {
          "code": "3058522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 762.9524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 310.23S",
      "code_information": [
        {
          "code": "3058526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1551,
          "minimum": 325.71,
          "maximum": 1135.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1135.6422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 02.7 CSS-072-27",
      "code_information": [
        {
          "code": "3058530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1347,
          "minimum": 282.87,
          "maximum": 986.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 986.2734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110 143110",
      "code_information": [
        {
          "code": "3058543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 683,
          "minimum": 143.43,
          "maximum": 500.0926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 500.0926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EPIDURAL 117\\\" INF 1633902",
      "code_information": [
        {
          "code": "3058611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE 10X5",
      "code_information": [
        {
          "code": "3058612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1239,
          "minimum": 260.19,
          "maximum": 907.1958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 907.1958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-FLOW 50 COBLATION",
      "code_information": [
        {
          "code": "3058620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1833,
          "minimum": 384.93,
          "maximum": 1342.1226,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1342.1226,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ACCOMINIZER 4.0",
      "code_information": [
        {
          "code": "3058623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 323.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STONCUTTER 5.5 7205331",
      "code_information": [
        {
          "code": "3058624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 956,
          "minimum": 200.76,
          "maximum": 699.9832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 699.9832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3058625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 ORBIT 7205323",
      "code_information": [
        {
          "code": "3058626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 466.4114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4.0 1864G",
      "code_information": [
        {
          "code": "3058639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL FLEX MED 27MM",
      "code_information": [
        {
          "code": "3058643",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 110.5622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I KNIFE SURG 8065921552",
      "code_information": [
        {
          "code": "3058653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.0234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 2.0MM 5820-010-020",
      "code_information": [
        {
          "code": "3058655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1105,
          "minimum": 232.05,
          "maximum": 809.081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 809.081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDO FEEDING 12FR X 60”",
      "code_information": [
        {
          "code": "3058693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MINI 4.0 283459",
      "code_information": [
        {
          "code": "3058696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1275,
          "minimum": 267.75,
          "maximum": 933.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 933.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 FULL RADIUS",
      "code_information": [
        {
          "code": "3058697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1275,
          "minimum": 267.75,
          "maximum": 933.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 933.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3058698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 919,
          "minimum": 192.99,
          "maximum": 672.8918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 672.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 018 14MMX34CM",
      "code_information": [
        {
          "code": "3058707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3097.9382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-240",
      "code_information": [
        {
          "code": "3058716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANOSCOPE-BEVELED DISP 103X18M",
      "code_information": [
        {
          "code": "3058720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-EXPEL NEPHR I/E 8.3/22",
      "code_information": [
        {
          "code": "3058729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1262,
          "minimum": 265.02,
          "maximum": 924.0364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 924.0364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH 15FR 71C",
      "code_information": [
        {
          "code": "3058737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-VPAD 2 INS-0050",
      "code_information": [
        {
          "code": "3058749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2207,
          "minimum": 463.47,
          "maximum": 1615.9654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1615.9654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-ALWAYS ON TIP INS-0352",
      "code_information": [
        {
          "code": "3058751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2136.5596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-19 GA ANSO INS-0382",
      "code_information": [
        {
          "code": "3058752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2136.5596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GA ANSO INS 0392",
      "code_information": [
        {
          "code": "3058753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2136.5596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GA NITINOL INS-5410",
      "code_information": [
        {
          "code": "3058754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4175,
          "minimum": 876.75,
          "maximum": 3056.935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3056.935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPINPERC INS-5600",
      "code_information": [
        {
          "code": "3058755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2207,
          "minimum": 463.47,
          "maximum": 1615.9654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1615.9654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE DISTRACTOR DISP",
      "code_information": [
        {
          "code": "3058766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 412.9608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE 1.5X36",
      "code_information": [
        {
          "code": "3058775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 AR 8943-16",
      "code_information": [
        {
          "code": "3058786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1013,
          "minimum": 212.73,
          "maximum": 741.7186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 741.7186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPIN EWC BIOPSY GUIDE",
      "code_information": [
        {
          "code": "3058788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3127,
          "minimum": 656.67,
          "maximum": 2289.5894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2289.5894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DISP SHOULDER 1.8MM",
      "code_information": [
        {
          "code": "3058805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1659,
          "minimum": 348.39,
          "maximum": 1214.7198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1214.7198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENTRAINER-AIR RT008",
      "code_information": [
        {
          "code": "3058809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 5.0 5050",
      "code_information": [
        {
          "code": "3058819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58043,
          "minimum": 12189.03,
          "maximum": 42499.0846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42499.0846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 7.0 7050",
      "code_information": [
        {
          "code": "3058820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60044,
          "minimum": 12609.24,
          "maximum": 43964.2168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43964.2168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 BV-1 M8709",
      "code_information": [
        {
          "code": "3058836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 546.9534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 2MMXxxCM",
      "code_information": [
        {
          "code": "3058843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4220,
          "minimum": 886.2,
          "maximum": 3089.884,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3089.884,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX20CM",
      "code_information": [
        {
          "code": "3058844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5064,
          "minimum": 1063.44,
          "maximum": 3707.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3707.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX30CM",
      "code_information": [
        {
          "code": "3058845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5591,
          "minimum": 1174.11,
          "maximum": 4093.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.7302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 CX ALL",
      "code_information": [
        {
          "code": "3058846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3097.9382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HEATED AIRVO 900PT501",
      "code_information": [
        {
          "code": "3058860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO MED OPT944",
      "code_information": [
        {
          "code": "3058862",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 239.4294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO LARGE OPT946",
      "code_information": [
        {
          "code": "3058863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 239.4294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-013-000 SZ4",
      "code_information": [
        {
          "code": "3058864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HEALING W/PLUG 30MM 95084",
      "code_information": [
        {
          "code": "3058868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 158.1552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN LITE FUD023",
      "code_information": [
        {
          "code": "3058869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.5MM",
      "code_information": [
        {
          "code": "3058875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CONTOUR CERVICAL 13-15",
      "code_information": [
        {
          "code": "3058876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-RIB UNIVERSAL 8” MALE",
      "code_information": [
        {
          "code": "3058877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3.0 1893G",
      "code_information": [
        {
          "code": "3058878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SLIM MED",
      "code_information": [
        {
          "code": "3058885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 170.6026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-SYSTEM UA2007",
      "code_information": [
        {
          "code": "3058887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 162,
          "minimum": 34.02,
          "maximum": 118.6164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 118.6164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WATER SUCTION BIOPSY VALVE",
      "code_information": [
        {
          "code": "3058903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 95.186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-ACCUSTAT 125NM S 801015",
      "code_information": [
        {
          "code": "3058929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5081,
          "minimum": 1067.01,
          "maximum": 3720.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3720.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MIDLINE 5FR BIO FLO",
      "code_information": [
        {
          "code": "3058932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 1.4X27MM",
      "code_information": [
        {
          "code": "3058955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3358,
          "minimum": 705.18,
          "maximum": 2458.7276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2458.7276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON,CAPIOX HPH-1000",
      "code_information": [
        {
          "code": "3058981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 623.8344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOBLADE GASTRO",
      "code_information": [
        {
          "code": "3058983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3696.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORTHOLOCK 3X110MM EX",
      "code_information": [
        {
          "code": "3058990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 684.607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X 343MM",
      "code_information": [
        {
          "code": "3058991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1159,
          "minimum": 243.39,
          "maximum": 848.6198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 848.6198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y935H",
      "code_information": [
        {
          "code": "3059006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.0X40X91MM",
      "code_information": [
        {
          "code": "3059015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 758.5592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-GENESYS HTA M006580211",
      "code_information": [
        {
          "code": "3059026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6769,
          "minimum": 1421.49,
          "maximum": 4956.2618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4956.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-CLEANING STICK 900PT602",
      "code_information": [
        {
          "code": "3059061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-QUADFUSE 9” EXT SMALLBORE",
      "code_information": [
        {
          "code": "3059062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.0096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED OPT316",
      "code_information": [
        {
          "code": "3059066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 522,
          "minimum": 109.62,
          "maximum": 382.2084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 382.2084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PED 900PT531",
      "code_information": [
        {
          "code": "3059068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 722,
          "minimum": 151.62,
          "maximum": 528.6484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 528.6484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-ABSOLUTE PSI-TEC",
      "code_information": [
        {
          "code": "3059124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-HEADREST SOFTOUCH",
      "code_information": [
        {
          "code": "3059127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ESOPHYX TIF R2007",
      "code_information": [
        {
          "code": "3059129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21712,
          "minimum": 4559.52,
          "maximum": 15897.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15897.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTER CONNECT PT-5558-F",
      "code_information": [
        {
          "code": "3059131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 3.5X195 700353",
      "code_information": [
        {
          "code": "3059137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1228,
          "minimum": 257.88,
          "maximum": 899.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 899.1416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACQUIRE EUS FND",
      "code_information": [
        {
          "code": "3059156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 2.0MM BIT",
      "code_information": [
        {
          "code": "3059170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2114,
          "minimum": 443.94,
          "maximum": 1547.8708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1547.8708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-IMPLANT SIZING SG - x",
      "code_information": [
        {
          "code": "3059171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIALYZER-HIGH FLUX 1.6 720DH16",
      "code_information": [
        {
          "code": "3059177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ULTRAPERC FULL 100/573/000",
      "code_information": [
        {
          "code": "3059178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1545,
          "minimum": 324.45,
          "maximum": 1131.249,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1131.249,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT MED",
      "code_information": [
        {
          "code": "3059179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 40.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENVEO PRO LOADING",
      "code_information": [
        {
          "code": "3059185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2618,
          "minimum": 549.78,
          "maximum": 1916.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1916.8996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 1.5MM NEEDLES",
      "code_information": [
        {
          "code": "3059187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 460,
          "minimum": 96.6,
          "maximum": 336.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 336.812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN 5X5CM FUD021",
      "code_information": [
        {
          "code": "3059209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-KNOTLESS S-TAK STEP 3MM",
      "code_information": [
        {
          "code": "3059213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW OSC SAGITTAL xxMM",
      "code_information": [
        {
          "code": "3059220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 456.8928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO DURACLIP 235CM 11MM",
      "code_information": [
        {
          "code": "3059232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1032.402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-HEEL PRESSURE MDT825",
      "code_information": [
        {
          "code": "3059240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT LG",
      "code_information": [
        {
          "code": "3059245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 40.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT SM",
      "code_information": [
        {
          "code": "3059246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 40.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-POLAR COMBO 1232PP",
      "code_information": [
        {
          "code": "3059252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 907,
          "minimum": 190.47,
          "maximum": 664.1054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 664.1054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-TRI STAPLE 2.0 SIG30AVM",
      "code_information": [
        {
          "code": "3059259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2871,
          "minimum": 602.91,
          "maximum": 2102.1462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2102.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND 1.0MM",
      "code_information": [
        {
          "code": "3059273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 935.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION LARGE",
      "code_information": [
        {
          "code": "3059275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION MED",
      "code_information": [
        {
          "code": "3059281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 279,
          "minimum": 58.59,
          "maximum": 204.2838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 204.2838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 15\\\" ADJ ILIO",
      "code_information": [
        {
          "code": "3059288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 328,
          "minimum": 68.88,
          "maximum": 240.1616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 240.1616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP ALL",
      "code_information": [
        {
          "code": "3059603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT 111645",
      "code_information": [
        {
          "code": "3059922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 570.3838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X140 143140",
      "code_information": [
        {
          "code": "3059924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1195,
          "minimum": 250.95,
          "maximum": 874.979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 874.979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LIGASURE SM  LF1212A",
      "code_information": [
        {
          "code": "3059951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3010,
          "minimum": 632.1,
          "maximum": 2203.922,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2203.922,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INJECTOR-LEVER EDGE    4100-01",
      "code_information": [
        {
          "code": "3059965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1454,
          "minimum": 305.34,
          "maximum": 1064.6188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1064.6188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ABC SINGLE FUNCTION",
      "code_information": [
        {
          "code": "3059973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 622.37,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATCHER-STONE WITH TUB 840-750",
      "code_information": [
        {
          "code": "3059984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 825,
          "minimum": 173.25,
          "maximum": 604.065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 604.065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP       7-382",
      "code_information": [
        {
          "code": "3059989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ISOLATOR  BIP   OSL2",
      "code_information": [
        {
          "code": "3059996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11959,
          "minimum": 2511.39,
          "maximum": 8756.3798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8756.3798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-LINEAR 60GRN      TX60G",
      "code_information": [
        {
          "code": "3060001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 913,
          "minimum": 191.73,
          "maximum": 668.4986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 668.4986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM GREEN        XR60G",
      "code_information": [
        {
          "code": "3060002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 550,
          "minimum": 115.5,
          "maximum": 402.71,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 402.71,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE   RC014MIBB",
      "code_information": [
        {
          "code": "3060082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 684.607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CORONARY PERFUSN 10004",
      "code_information": [
        {
          "code": "3060083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.7928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEX IRIS     611.75",
      "code_information": [
        {
          "code": "3060129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 858,
          "minimum": 180.18,
          "maximum": 628.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 628.2276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 8\\\"  7708-000-10",
      "code_information": [
        {
          "code": "3060132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 230.643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VESSEL           30003",
      "code_information": [
        {
          "code": "3060134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 101,
          "minimum": 21.21,
          "maximum": 73.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 73.9522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SWANSON SUTURE  11-0675",
      "code_information": [
        {
          "code": "3060151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 726.3424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-T-TUBE 16FR       0099830",
      "code_information": [
        {
          "code": "3060199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-RETRACTO 12\\\" 1041",
      "code_information": [
        {
          "code": "3060247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE MEDIUM   9893",
      "code_information": [
        {
          "code": "3060289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 364.6356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH      SZ5  A0A04",
      "code_information": [
        {
          "code": "3060306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 191.1042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-UNIV     60-6010-001",
      "code_information": [
        {
          "code": "3060315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 395.388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERZ-REFLECTIVE PK   PM 8005",
      "code_information": [
        {
          "code": "3060317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.7928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-SPRING CLIP 6MM  CSOFT6",
      "code_information": [
        {
          "code": "3060318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 188.9076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-SILVERSTEIN PK 1428010",
      "code_information": [
        {
          "code": "3060385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 153.0298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0 CT-2 Z332H",
      "code_information": [
        {
          "code": "3060417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROGRAMMER-TEST STIM 3531",
      "code_information": [
        {
          "code": "3060442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2604,
          "minimum": 546.84,
          "maximum": 1906.6488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1906.6488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MINI HOOK 357501",
      "code_information": [
        {
          "code": "3060443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 341.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 4.0MM 03.000.012S",
      "code_information": [
        {
          "code": "3060451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 745,
          "minimum": 156.45,
          "maximum": 545.489,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 545.489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 5.0MM 03.000.015S",
      "code_information": [
        {
          "code": "3060452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 395.388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90X9.5 05.003.126S",
      "code_information": [
        {
          "code": "3060455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 624,
          "minimum": 131.04,
          "maximum": 456.8928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 456.8928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 10M",
      "code_information": [
        {
          "code": "3060460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3512,
          "minimum": 737.52,
          "maximum": 2571.4864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2571.4864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT",
      "code_information": [
        {
          "code": "3060472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 5MM PAL-508LL",
      "code_information": [
        {
          "code": "3060475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 541.828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-FAST FIX 360 KPSC",
      "code_information": [
        {
          "code": "3060478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1344,
          "minimum": 282.24,
          "maximum": 984.0768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 984.0768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU RIGHT 7210424",
      "code_information": [
        {
          "code": "3060485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1334,
          "minimum": 280.14,
          "maximum": 976.7548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 976.7548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU LEFT 7210423",
      "code_information": [
        {
          "code": "3060486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 948.199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STRT 7210426",
      "code_information": [
        {
          "code": "3060488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 948.199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.3MM CROSSPIN 62-23333",
      "code_information": [
        {
          "code": "3060489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1070.4764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STR 7210425",
      "code_information": [
        {
          "code": "3060494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 917.4466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SILICONE 8CM        205108",
      "code_information": [
        {
          "code": "3061090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1750,
          "minimum": 367.5,
          "maximum": 1281.35,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1281.35,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-SINGLE HOLE 1877-01-010",
      "code_information": [
        {
          "code": "3062492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2040,
          "minimum": 428.4,
          "maximum": 1493.688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1493.688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-3' EPV100 VENT",
      "code_information": [
        {
          "code": "3068320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.9384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX PEDS MAXP",
      "code_information": [
        {
          "code": "3068323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP VIBRATORY ACAPELLA",
      "code_information": [
        {
          "code": "3068325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 509,
          "minimum": 106.89,
          "maximum": 372.6898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 372.6898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED W/7' TUBING",
      "code_information": [
        {
          "code": "3068327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BIPAP PERFORMATRAK LARGE",
      "code_information": [
        {
          "code": "3068330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT DUAL LIMB",
      "code_information": [
        {
          "code": "3068331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT CAPNOXYGEN C02-01",
      "code_information": [
        {
          "code": "3068332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.6472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT/PED 8’ 58051",
      "code_information": [
        {
          "code": "3068333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-MYOSURE            40-902",
      "code_information": [
        {
          "code": "3078533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 171,
          "minimum": 35.91,
          "maximum": 125.2062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.2062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-DURA           20-xxxx",
      "code_information": [
        {
          "code": "3078541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5964,
          "minimum": 1252.44,
          "maximum": 4366.8408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4366.8408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-DURAL           1314",
      "code_information": [
        {
          "code": "3078593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH INDWELLING SLIT 295-6",
      "code_information": [
        {
          "code": "3078730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1143.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-KARLEN BALLOON    CS-01700",
      "code_information": [
        {
          "code": "3078823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML 0797208",
      "code_information": [
        {
          "code": "3078850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 163.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU, DIALYSIS 2.5% 2L 5B9876",
      "code_information": [
        {
          "code": "3078852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 497,
          "minimum": 104.37,
          "maximum": 363.9034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 363.9034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML  07138-09",
      "code_information": [
        {
          "code": "3078858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 51,
          "minimum": 10.71,
          "maximum": 37.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK E3773-45C",
      "code_information": [
        {
          "code": "3078982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1254,
          "minimum": 263.34,
          "maximum": 918.1788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 918.1788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MAS TLIF LIGHT   3400033",
      "code_information": [
        {
          "code": "3079040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2088.9666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MULTILEAD TRIAL     3013",
      "code_information": [
        {
          "code": "3079055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1144,
          "minimum": 240.24,
          "maximum": 837.6368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 837.6368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.0X13        AR-8400EX",
      "code_information": [
        {
          "code": "3079215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 333.151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.-X13 AR-8500EX",
      "code_information": [
        {
          "code": "3079228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 332.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL G2 TIP 35CM",
      "code_information": [
        {
          "code": "3079250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3329,
          "minimum": 699.09,
          "maximum": 2437.4938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2437.4938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 ABRADER    72201518",
      "code_information": [
        {
          "code": "3079252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 656,
          "minimum": 137.76,
          "maximum": 480.3232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 480.3232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR    72201513",
      "code_information": [
        {
          "code": "3079253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 637,
          "minimum": 133.77,
          "maximum": 466.4114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 466.4114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3079254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.8556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5 FULL RADIUS 7205305",
      "code_information": [
        {
          "code": "3079257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 333.151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-4.5 AGGRESSIVE",
      "code_information": [
        {
          "code": "3079259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 FULL RADIUM 7205306",
      "code_information": [
        {
          "code": "3079261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 323.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 INCISOR     7205345",
      "code_information": [
        {
          "code": "3079262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 323.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL 45CM    NSLG2C45A",
      "code_information": [
        {
          "code": "3079282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3167,
          "minimum": 665.07,
          "maximum": 2318.8774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2318.8774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 36\\\"   HAR36",
      "code_information": [
        {
          "code": "3079285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3146,
          "minimum": 660.66,
          "maximum": 2303.5012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2303.5012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HS FOCUS 9CM CRVD  HAR9F",
      "code_information": [
        {
          "code": "3079290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2871,
          "minimum": 602.91,
          "maximum": 2102.1462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2102.1462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INPUT 8FR PS    080011",
      "code_information": [
        {
          "code": "3079468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNLER SM-LG    9009-s",
      "code_information": [
        {
          "code": "3079475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 766,
          "minimum": 160.86,
          "maximum": 560.8652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 560.8652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-RENAL 20CM      900-123",
      "code_information": [
        {
          "code": "3079482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 432,
          "minimum": 90.72,
          "maximum": 316.3104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 316.3104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-EXT BILATERAL DYNJP8004A",
      "code_information": [
        {
          "code": "3079499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-CORNEAL DISP      E5699",
      "code_information": [
        {
          "code": "3079626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 78.3454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST-OP XL MALE      1315",
      "code_information": [
        {
          "code": "3079661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 102.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909504",
      "code_information": [
        {
          "code": "3079703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11962,
          "minimum": 2512.02,
          "maximum": 8758.5764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8758.5764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5070",
      "code_information": [
        {
          "code": "3079707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3761,
          "minimum": 789.81,
          "maximum": 2753.8042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2753.8042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5071",
      "code_information": [
        {
          "code": "3079709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3761,
          "minimum": 789.81,
          "maximum": 2753.8042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2753.8042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PHACO .9MM  8065-750517",
      "code_information": [
        {
          "code": "3079736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 429,
          "minimum": 90.09,
          "maximum": 314.1138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.1138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SMALL VIT PLUS 1",
      "code_information": [
        {
          "code": "3079745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1675,
          "minimum": 351.75,
          "maximum": 1226.435,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1226.435,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STAR            AR-1606",
      "code_information": [
        {
          "code": "3079766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 877,
          "minimum": 184.17,
          "maximum": 642.1394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 642.1394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 12MM        CB12LT",
      "code_information": [
        {
          "code": "3079770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1106,
          "minimum": 232.26,
          "maximum": 809.8132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 809.8132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM KII          CFS22",
      "code_information": [
        {
          "code": "3079789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.8332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-FIBER          AR-7209SN",
      "code_information": [
        {
          "code": "3079790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM THREADED KII CTS22",
      "code_information": [
        {
          "code": "3079792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.8332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM THREADED KII  CTS0S",
      "code_information": [
        {
          "code": "3079793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.3656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SILICONE         400561",
      "code_information": [
        {
          "code": "3079975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 550,
          "minimum": 115.5,
          "maximum": 402.71,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 402.71,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER MINI        1500",
      "code_information": [
        {
          "code": "3079992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 429.8014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER SMALL       1500",
      "code_information": [
        {
          "code": "3079994",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 554,
          "minimum": 116.34,
          "maximum": 405.6388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 405.6388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER PETITE      1500",
      "code_information": [
        {
          "code": "3079996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 587,
          "minimum": 123.27,
          "maximum": 429.8014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 429.8014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-AGGRESSIVE 3.5   283315",
      "code_information": [
        {
          "code": "3080062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 419.5506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ULTRA AGGRESSIVE 283325",
      "code_information": [
        {
          "code": "3080067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 419.5506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.5MM AR-1204AS-95",
      "code_information": [
        {
          "code": "3080073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2182,
          "minimum": 458.22,
          "maximum": 1597.6604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1597.6604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 10MM AR-1204AS-100",
      "code_information": [
        {
          "code": "3080074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1596.9282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.0MM AR1204AS90",
      "code_information": [
        {
          "code": "3080075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1819,
          "minimum": 381.99,
          "maximum": 1331.8718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1331.8718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-OPTIMOLD NASAL   PS1688",
      "code_information": [
        {
          "code": "3080204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 89.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3080355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 352,
          "minimum": 73.92,
          "maximum": 257.7344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 257.7344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-EGIA 60 MED   EGIA60AVM",
      "code_information": [
        {
          "code": "3080925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-ENDOCLIP MULTI    ER320",
      "code_information": [
        {
          "code": "3080932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 859,
          "minimum": 180.39,
          "maximum": 628.9598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 628.9598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR VASCULAR  TX30V",
      "code_information": [
        {
          "code": "3081085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 703.6442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT 12”",
      "code_information": [
        {
          "code": "3081101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT RIGHT",
      "code_information": [
        {
          "code": "3081102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY RT ANGLE Y PORT 12”",
      "code_information": [
        {
          "code": "3081103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL HEALTHVENT 24HR 97021",
      "code_information": [
        {
          "code": "3081122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 155.2264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIEDER TS101DC",
      "code_information": [
        {
          "code": "3081129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 594,
          "minimum": 124.74,
          "maximum": 434.9268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 434.9268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-POLYSORB 55      SZ 200",
      "code_information": [
        {
          "code": "3081173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4940,
          "minimum": 1037.4,
          "maximum": 3617.068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3617.068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN INSORB 2030",
      "code_information": [
        {
          "code": "3081400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 894,
          "minimum": 187.74,
          "maximum": 654.5868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 654.5868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZS ECS's",
      "code_information": [
        {
          "code": "3081408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1763,
          "minimum": 370.23,
          "maximum": 1290.8686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1290.8686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZ CDHxxA",
      "code_information": [
        {
          "code": "3081415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1570,
          "minimum": 329.7,
          "maximum": 1149.554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1149.554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWER  PLEE60A",
      "code_information": [
        {
          "code": "3081416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2611,
          "minimum": 548.31,
          "maximum": 1911.7742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1911.7742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWERED PCE60A",
      "code_information": [
        {
          "code": "3081432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2475,
          "minimum": 519.75,
          "maximum": 1812.195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1812.195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 45       EC45A",
      "code_information": [
        {
          "code": "3081433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2038,
          "minimum": 427.98,
          "maximum": 1492.2236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1492.2236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 60       EC60A",
      "code_information": [
        {
          "code": "3081436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2635,
          "minimum": 553.35,
          "maximum": 1929.347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1929.347,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-EGIA HANDLE  EGIAUSTND",
      "code_information": [
        {
          "code": "3081443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2985,
          "minimum": 626.85,
          "maximum": 2185.617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2185.617,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDO GIA UNIVER 030449",
      "code_information": [
        {
          "code": "3081491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1933.008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-THICK TISSUE      TRT75",
      "code_information": [
        {
          "code": "3081494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3081502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT STR 35WD",
      "code_information": [
        {
          "code": "3081503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 80.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAYS-SURGICAL PACK    3311-8G",
      "code_information": [
        {
          "code": "3081506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER   TLC-75",
      "code_information": [
        {
          "code": "3081530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 60BL      TX60B",
      "code_information": [
        {
          "code": "3081535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 661.9088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR  40B     CS40B",
      "code_information": [
        {
          "code": "3081542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3019,
          "minimum": 633.99,
          "maximum": 2210.5118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2210.5118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40G      CS40G",
      "code_information": [
        {
          "code": "3081544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3019,
          "minimum": 633.99,
          "maximum": 2210.5118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2210.5118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDOPATH VASC PVE35A",
      "code_information": [
        {
          "code": "3081550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2231,
          "minimum": 468.51,
          "maximum": 1633.5382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1633.5382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-HEAVY WIRE 90    TLH90",
      "code_information": [
        {
          "code": "3081554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 791,
          "minimum": 166.11,
          "maximum": 579.1702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 579.1702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3081569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A28-2",
      "code_information": [
        {
          "code": "3082047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21603,
          "minimum": 4536.63,
          "maximum": 15817.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15817.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A25-25",
      "code_information": [
        {
          "code": "3082066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21603,
          "minimum": 4536.63,
          "maximum": 15817.7166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15817.7166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-AAA MAIN    ETCF3636C49E",
      "code_information": [
        {
          "code": "3082068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20042,
          "minimum": 4208.82,
          "maximum": 14674.7524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 14674.7524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STICK-FIBER            AR-7209",
      "code_information": [
        {
          "code": "3082089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKINETTE-BARRIER   NON22535",
      "code_information": [
        {
          "code": "3082135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE FOOT        014407",
      "code_information": [
        {
          "code": "3082217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 659,
          "minimum": 138.39,
          "maximum": 482.5198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 482.5198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRAIGHT           1123",
      "code_information": [
        {
          "code": "3082330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 274,
          "minimum": 57.54,
          "maximum": 200.6228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 200.6228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUMP-PERICARDIAL 1/4 CONNECTOR",
      "code_information": [
        {
          "code": "3082395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 132.5282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPRALOOP-BRUCKER/MESSROGHLI",
      "code_information": [
        {
          "code": "3082421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1727,
          "minimum": 362.67,
          "maximum": 1264.5094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1264.5094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-NUKNITT 3X4      1943",
      "code_information": [
        {
          "code": "3082430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC-0       173024",
      "code_information": [
        {
          "code": "3082450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 631.1564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC 2-0 173023",
      "code_information": [
        {
          "code": "3082453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 631.1564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 698G",
      "code_information": [
        {
          "code": "3082542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-GORETEX CV-3      3N06A",
      "code_information": [
        {
          "code": "3082544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 423,
          "minimum": 88.83,
          "maximum": 309.7206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 309.7206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J947H",
      "code_information": [
        {
          "code": "3082558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONO PDSII        Z740D",
      "code_information": [
        {
          "code": "3082562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 305,
          "minimum": 64.05,
          "maximum": 223.321,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 223.321,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ALIANCE        5060-05",
      "code_information": [
        {
          "code": "3082566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-FLOSEAL 10ML   1503352",
      "code_information": [
        {
          "code": "3082592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2592,
          "minimum": 544.32,
          "maximum": 1897.8624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1897.8624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING NEMA   3730ANS",
      "code_information": [
        {
          "code": "3082996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2891.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ACCESSORY           502",
      "code_information": [
        {
          "code": "3083003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4011,
          "minimum": 842.31,
          "maximum": 2936.8542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2936.8542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BIOGLUE 5ML  BG3515-5US",
      "code_information": [
        {
          "code": "3083007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5122,
          "minimum": 1075.62,
          "maximum": 3750.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3750.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANS CATH 10\\\" PM040-A",
      "code_information": [
        {
          "code": "3083014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1368,
          "minimum": 287.28,
          "maximum": 1001.6496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1001.6496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-CYSTO 25X5/8  581610",
      "code_information": [
        {
          "code": "3083019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 50,
          "minimum": 10.5,
          "maximum": 36.61,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 36.61,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE VNUS        CFP",
      "code_information": [
        {
          "code": "3083021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION CATH  PM010-A",
      "code_information": [
        {
          "code": "3083022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 435,
          "minimum": 91.35,
          "maximum": 318.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 318.507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION 5\\\"    PM020-A",
      "code_information": [
        {
          "code": "3083023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 438.5878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-COLLECTION   003984-901",
      "code_information": [
        {
          "code": "3083083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 149.3688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-STERIDRAPE 8 7/8   1075",
      "code_information": [
        {
          "code": "3083104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URETERAL DIAL   240-100",
      "code_information": [
        {
          "code": "3083141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1497,
          "minimum": 314.37,
          "maximum": 1096.1034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1096.1034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-PROTACK DEVICE 5MM",
      "code_information": [
        {
          "code": "3083191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3464,
          "minimum": 727.44,
          "maximum": 2536.3408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2536.3408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB AR-13226",
      "code_information": [
        {
          "code": "3083200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 596,
          "minimum": 125.16,
          "maximum": 436.3912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 436.3912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-BONE SCREW 3.5X50  311.349",
      "code_information": [
        {
          "code": "3083203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.35 2883-02-043",
      "code_information": [
        {
          "code": "3083212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1768.9952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-IQ DISPOSABLE 72-1010",
      "code_information": [
        {
          "code": "3083214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 688.268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-GLOW AND TELL     1100-20",
      "code_information": [
        {
          "code": "3083225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 409.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-          AR-7237-7T",
      "code_information": [
        {
          "code": "3083486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 520,
          "minimum": 109.2,
          "maximum": 380.744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 380.744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS2",
      "code_information": [
        {
          "code": "3083597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-BIOGLUE FAN        BGST-12",
      "code_information": [
        {
          "code": "3083615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 177.1924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE ALL    UMx67x's",
      "code_information": [
        {
          "code": "3083622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1067,
          "minimum": 224.07,
          "maximum": 781.2574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 781.2574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 35CM     3908",
      "code_information": [
        {
          "code": "3083637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 341.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CURVED DISP I&A 8065751512",
      "code_information": [
        {
          "code": "3083715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE POLYMER I/A",
      "code_information": [
        {
          "code": "3083720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 222,
          "minimum": 46.62,
          "maximum": 162.5484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 162.5484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-TURBOSONICS     8065750853",
      "code_information": [
        {
          "code": "3083760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 546.9534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-VACURRETTE 5MM       21664",
      "code_information": [
        {
          "code": "3083764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-TUNNELING            1112",
      "code_information": [
        {
          "code": "3084399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 384.405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-LUKI MUCOUS SPEC  8646-04",
      "code_information": [
        {
          "code": "3084800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 6",
      "code_information": [
        {
          "code": "3084821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 688.268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA70",
      "code_information": [
        {
          "code": "3084824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 956.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA80",
      "code_information": [
        {
          "code": "3084827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1345,
          "minimum": 282.45,
          "maximum": 984.809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 984.809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/METER ALL P4PxxSD",
      "code_information": [
        {
          "code": "3084870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1    4609764",
      "code_information": [
        {
          "code": "3084884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 112.7588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAPS-FINGER DISP PACK 9900s",
      "code_information": [
        {
          "code": "3084885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 139.118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-LAP CB EXPLOR    G26908",
      "code_information": [
        {
          "code": "3084925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3560,
          "minimum": 747.6,
          "maximum": 2606.632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2606.632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SOLU IRRISEPT .5% CHG",
      "code_information": [
        {
          "code": "3084928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 797,
          "minimum": 167.37,
          "maximum": 583.5634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 583.5634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INFLATION   03.804.413S",
      "code_information": [
        {
          "code": "3084946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP 26-23-0757",
      "code_information": [
        {
          "code": "3084992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 206.4804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFF74",
      "code_information": [
        {
          "code": "3085110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-100LP",
      "code_information": [
        {
          "code": "3085111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 906,
          "minimum": 190.26,
          "maximum": 663.3732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 663.3732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED     CTF73",
      "code_information": [
        {
          "code": "3085112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-100L",
      "code_information": [
        {
          "code": "3085113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 941,
          "minimum": 197.61,
          "maximum": 689.0002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 689.0002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREATED      CTF03",
      "code_information": [
        {
          "code": "3085117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-8MM KII OPTICAL   COQ19",
      "code_information": [
        {
          "code": "3085120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR47",
      "code_information": [
        {
          "code": "3085135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR85",
      "code_information": [
        {
          "code": "3085137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM KII OPTICAL  COR37",
      "code_information": [
        {
          "code": "3085140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 567,
          "minimum": 119.07,
          "maximum": 415.1574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 415.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM LONG         C0R39",
      "code_information": [
        {
          "code": "3085142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 567,
          "minimum": 119.07,
          "maximum": 415.1574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 415.1574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM KII FIOS      CFFxx",
      "code_information": [
        {
          "code": "3085145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM LONG BLADED CFB71",
      "code_information": [
        {
          "code": "3085160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-THORACOPOR 11.5  179303",
      "code_information": [
        {
          "code": "3085163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 882,
          "minimum": 185.22,
          "maximum": 645.8004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 645.8004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM THREADED     CTF33",
      "code_information": [
        {
          "code": "3085165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-SPLIT           82-4095",
      "code_information": [
        {
          "code": "3085170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2007,
          "minimum": 421.47,
          "maximum": 1469.5254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1469.5254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL BLADELESS     B8LT",
      "code_information": [
        {
          "code": "3085202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 482,
          "minimum": 101.22,
          "maximum": 352.9204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 352.9204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP LONG VS101505",
      "code_information": [
        {
          "code": "3085203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1367,
          "minimum": 287.07,
          "maximum": 1000.9174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1000.9174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 5MM           B5LT",
      "code_information": [
        {
          "code": "3085207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1543,
          "minimum": 324.03,
          "maximum": 1129.7846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1129.7846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 12X100MM     H12LP",
      "code_information": [
        {
          "code": "3085208",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 702,
          "minimum": 147.42,
          "maximum": 514.0044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 514.0044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN CUFF 7.0MM",
      "code_information": [
        {
          "code": "3085522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BIO PREP BONE PREP",
      "code_information": [
        {
          "code": "3085533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1349,
          "minimum": 283.29,
          "maximum": 987.7378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 987.7378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SPIKE INFILTRATION",
      "code_information": [
        {
          "code": "3085534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 132.5282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 8.0FR MEGA IAB",
      "code_information": [
        {
          "code": "3085537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1496,
          "minimum": 314.16,
          "maximum": 1095.3712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1095.3712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ARMSTRONG TEFLON DRAIN",
      "code_information": [
        {
          "code": "3085540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 163.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-TIBIAL 111651",
      "code_information": [
        {
          "code": "3085541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 311.9172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PROCEDURE TRACKING 107130",
      "code_information": [
        {
          "code": "3085542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 997.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE 111320",
      "code_information": [
        {
          "code": "3085543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 405,
          "minimum": 85.05,
          "maximum": 296.541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 296.541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX IMPACTION",
      "code_information": [
        {
          "code": "3085544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 817,
          "minimum": 171.57,
          "maximum": 598.2074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 598.2074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144140",
      "code_information": [
        {
          "code": "3085545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 691.929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX 116230",
      "code_information": [
        {
          "code": "3085546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 688.268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON ULTRASIL",
      "code_information": [
        {
          "code": "3085560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-ENDO EXCEL 15MM   B15LT",
      "code_information": [
        {
          "code": "3085620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1548,
          "minimum": 325.08,
          "maximum": 1133.4456,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1133.4456,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR ARMSTRONG    10-56121",
      "code_information": [
        {
          "code": "3085635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 156.6908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR PAPARELLA 1.14MM",
      "code_information": [
        {
          "code": "3085636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 156.6908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACHEAL EMG  8229307",
      "code_information": [
        {
          "code": "3085638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1585,
          "minimum": 332.85,
          "maximum": 1160.537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1160.537,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH ALL SZS 822970x",
      "code_information": [
        {
          "code": "3085644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2020.1398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 20FR   0100-20",
      "code_information": [
        {
          "code": "3085648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-KAMVAC            5300-00",
      "code_information": [
        {
          "code": "3085723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 646.5326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MOSS GASTROSTOMY  5-17719",
      "code_information": [
        {
          "code": "3085779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1351.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM PROX",
      "code_information": [
        {
          "code": "3085796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 494.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T MODIFIED        24-0072",
      "code_information": [
        {
          "code": "3085882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.8396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COLLECTION DISP BKT-506",
      "code_information": [
        {
          "code": "3086006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 221.1244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OXYFLEX        SA008000",
      "code_information": [
        {
          "code": "3086095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX INFLOW  AQL-110",
      "code_information": [
        {
          "code": "3086102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      80-9102",
      "code_information": [
        {
          "code": "3086103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 715,
          "minimum": 150.15,
          "maximum": 523.523,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 523.523,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      5120-10",
      "code_information": [
        {
          "code": "3086105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 167.6738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AIRSEAL ASM-EVAC",
      "code_information": [
        {
          "code": "3086106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 963,
          "minimum": 202.23,
          "maximum": 705.1086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 705.1086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATOR STR  18-95522",
      "code_information": [
        {
          "code": "3086107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 542,
          "minimum": 113.82,
          "maximum": 396.8524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 396.8524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LASER VACUUM    VT10424",
      "code_information": [
        {
          "code": "3086109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.1116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LIPOSUCTION   DYND50112",
      "code_information": [
        {
          "code": "3086110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MAIN PUMP       AR-6410",
      "code_information": [
        {
          "code": "3086111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 560.133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/4\\\"X1/16\\\"X8'      3108",
      "code_information": [
        {
          "code": "3086139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 132,
          "minimum": 27.72,
          "maximum": 96.6504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 96.6504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OUTFLOW         AR-6430",
      "code_information": [
        {
          "code": "3086141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO      284508",
      "code_information": [
        {
          "code": "3086142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 450,
          "minimum": 94.5,
          "maximum": 329.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 329.49,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO IRRIG OUT",
      "code_information": [
        {
          "code": "3086144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 445.9098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-ASPIRATION AT-10003-6",
      "code_information": [
        {
          "code": "3086181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 144.2434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TISSEEL         0600065",
      "code_information": [
        {
          "code": "3086182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 629,
          "minimum": 132.09,
          "maximum": 460.5538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 460.5538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TRANSDUCER 48 61000",
      "code_information": [
        {
          "code": "3086185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 148.6366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARTHREX-TIB CANN      AR-1802D",
      "code_information": [
        {
          "code": "3086190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.1956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-& TIP-SMALL   9009-18",
      "code_information": [
        {
          "code": "3086203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 821,
          "minimum": 172.41,
          "maximum": 601.1362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 601.1362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER & TIP-LARGE   9009-16",
      "code_information": [
        {
          "code": "3086205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 724,
          "minimum": 152.04,
          "maximum": 530.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 530.1128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-STIMULATOR LEAD   402",
      "code_information": [
        {
          "code": "3086210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3245,
          "minimum": 681.45,
          "maximum": 2375.989,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2375.989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE SUPPORT 79-82160",
      "code_information": [
        {
          "code": "3086407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 70x-xxxx ALL SIZES",
      "code_information": [
        {
          "code": "3086409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM VAS          XR30V",
      "code_information": [
        {
          "code": "3086955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 443,
          "minimum": 93.03,
          "maximum": 324.3646,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 324.3646,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH 2-0   170057",
      "code_information": [
        {
          "code": "3086965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 813,
          "minimum": 170.73,
          "maximum": 595.2786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 595.2786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VAC-SUPER TURBO     ASC4250-01",
      "code_information": [
        {
          "code": "3087110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1070.4764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP CVD ALL 21500s",
      "code_information": [
        {
          "code": "3087119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CURVED 7MM     21853",
      "code_information": [
        {
          "code": "3087130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 73.22,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 8MM CVD   20317",
      "code_information": [
        {
          "code": "3087132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VOICE-PROLARYN        8044M0K5",
      "code_information": [
        {
          "code": "3087140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3836,
          "minimum": 805.56,
          "maximum": 2808.7192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2808.7192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVULATOME-LEMAITRE   1009-00",
      "code_information": [
        {
          "code": "3087919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 13534,
          "minimum": 2842.14,
          "maximum": 9909.5948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 9909.5948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8916-14",
      "code_information": [
        {
          "code": "3087939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 812,
          "minimum": 170.52,
          "maximum": 594.5464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 594.5464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 UNDYED    VLOCM1904",
      "code_information": [
        {
          "code": "3088955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 396.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J761D",
      "code_information": [
        {
          "code": "3088965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.2604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VIOLET    VLOCM0804",
      "code_information": [
        {
          "code": "3088967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 557,
          "minimum": 116.97,
          "maximum": 407.8354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 407.8354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J441",
      "code_information": [
        {
          "code": "3088976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8.7864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS2     1666G",
      "code_information": [
        {
          "code": "3088979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J218H",
      "code_information": [
        {
          "code": "3088985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y495G",
      "code_information": [
        {
          "code": "3088991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 78.3454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       D5526",
      "code_information": [
        {
          "code": "3088992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 799,
          "minimum": 167.79,
          "maximum": 585.0278,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 585.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 6-0           Z432H",
      "code_information": [
        {
          "code": "3088993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0  ALL  833-000s",
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        {
          "code": "3088998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 390.2626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J727D",
      "code_information": [
        {
          "code": "3089002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J905T",
      "code_information": [
        {
          "code": "3089005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J739D",
      "code_information": [
        {
          "code": "3089007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J906G",
      "code_information": [
        {
          "code": "3089013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.3656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          J740D",
      "code_information": [
        {
          "code": "3089014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J775D",
      "code_information": [
        {
          "code": "3089024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 120.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J789D",
      "code_information": [
        {
          "code": "3089025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z881G",
      "code_information": [
        {
          "code": "3089026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8806H",
      "code_information": [
        {
          "code": "3089027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z990G",
      "code_information": [
        {
          "code": "3089030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J834G",
      "code_information": [
        {
          "code": "3089039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J833G",
      "code_information": [
        {
          "code": "3089042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8824G",
      "code_information": [
        {
          "code": "3089048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.1998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y493G",
      "code_information": [
        {
          "code": "3089059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y490G",
      "code_information": [
        {
          "code": "3089060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 73.22,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8521H",
      "code_information": [
        {
          "code": "3089064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8581H",
      "code_information": [
        {
          "code": "3089065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8557H",
      "code_information": [
        {
          "code": "3089066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8833H",
      "code_information": [
        {
          "code": "3089069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8623H",
      "code_information": [
        {
          "code": "3089072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8522H",
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        {
          "code": "3089073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       8534H",
      "code_information": [
        {
          "code": "3089074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J904T",
      "code_information": [
        {
          "code": "3089079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      PX82H",
      "code_information": [
        {
          "code": "3089097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8523H",
      "code_information": [
        {
          "code": "3089100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8805H",
      "code_information": [
        {
          "code": "3089105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 163.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8709H",
      "code_information": [
        {
          "code": "3089106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 266,
          "minimum": 55.86,
          "maximum": 194.7652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 194.7652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8720H",
      "code_information": [
        {
          "code": "3089110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 143.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8556H",
      "code_information": [
        {
          "code": "3089113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8710H",
      "code_information": [
        {
          "code": "3089114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 65.1658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8304H",
      "code_information": [
        {
          "code": "3089117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 240,
          "minimum": 50.4,
          "maximum": 175.728,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 175.728,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8703H",
      "code_information": [
        {
          "code": "3089121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 251,
          "minimum": 52.71,
          "maximum": 183.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 183.7822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J213H",
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        {
          "code": "3089123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO       AR-4068-xxx",
      "code_information": [
        {
          "code": "3089131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1070.4764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         G124H",
      "code_information": [
        {
          "code": "3089132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         U256H",
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        {
          "code": "3089133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 2-0       G123H",
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        {
          "code": "3089145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       1792G",
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        {
          "code": "3089146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 195.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
      "code_information": [
        {
          "code": "3089147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 248,
          "minimum": 52.08,
          "maximum": 181.5856,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 181.5856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 0       L104G",
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        {
          "code": "3089150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       G172H",
      "code_information": [
        {
          "code": "3089154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U203",
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        {
          "code": "3089156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1637G",
      "code_information": [
        {
          "code": "3089157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0     1916G",
      "code_information": [
        {
          "code": "3089161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     1824H",
      "code_information": [
        {
          "code": "3089172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A304H",
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        {
          "code": "3089177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 5-0          K890H",
      "code_information": [
        {
          "code": "3089195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 4-0           709H",
      "code_information": [
        {
          "code": "3089202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 118,
          "minimum": 24.78,
          "maximum": 86.3996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 86.3996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0  X524H",
      "code_information": [
        {
          "code": "3089204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5        B449T",
      "code_information": [
        {
          "code": "3089212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 4-0      X204H",
      "code_information": [
        {
          "code": "3089217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 3-0      X936H",
      "code_information": [
        {
          "code": "3089226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5-0      X727H",
      "code_information": [
        {
          "code": "3089227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        690G",
      "code_information": [
        {
          "code": "3089238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1663H",
      "code_information": [
        {
          "code": "3089244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z340H",
      "code_information": [
        {
          "code": "3089254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7.322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 0         L880G",
      "code_information": [
        {
          "code": "3089258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      SXP82",
      "code_information": [
        {
          "code": "3089266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 607,
          "minimum": 127.47,
          "maximum": 444.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 444.4454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND2-0       SXP86",
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        {
          "code": "3089267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 666,
          "minimum": 139.86,
          "maximum": 487.6452,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 487.6452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X927H",
      "code_information": [
        {
          "code": "3089281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z879G",
      "code_information": [
        {
          "code": "3089283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0 Z494G",
      "code_information": [
        {
          "code": "3089284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0        687G",
      "code_information": [
        {
          "code": "3089287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.8268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X513H",
      "code_information": [
        {
          "code": "3089288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 46.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2 MX69G",
      "code_information": [
        {
          "code": "3089290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 216,
          "minimum": 45.36,
          "maximum": 158.1552,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 158.1552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS O EZ10G",
      "code_information": [
        {
          "code": "3089291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 283.3614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          EJ10G",
      "code_information": [
        {
          "code": "3089292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 283.3614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       M8720",
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        {
          "code": "3089293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 622,
          "minimum": 130.62,
          "maximum": 455.4284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 455.4284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       M8303",
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        {
          "code": "3089294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 778,
          "minimum": 163.38,
          "maximum": 569.6516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 569.6516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       U202H",
      "code_information": [
        {
          "code": "3089307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U213H",
      "code_information": [
        {
          "code": "3089308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8843H",
      "code_information": [
        {
          "code": "3089314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.1658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J555G",
      "code_information": [
        {
          "code": "3089316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 132.5282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            C027D",
      "code_information": [
        {
          "code": "3089318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.0096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX45D",
      "code_information": [
        {
          "code": "3089320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 207,
          "minimum": 43.47,
          "maximum": 151.5654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 151.5654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 8-0         2815G",
      "code_information": [
        {
          "code": "3089323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 148.6366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X523H",
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        {
          "code": "3089324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X977H",
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        {
          "code": "3089325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0           Z774D",
      "code_information": [
        {
          "code": "3089328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 221.1244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 10-0      9003G",
      "code_information": [
        {
          "code": "3089335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 189.6398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        793G",
      "code_information": [
        {
          "code": "3089348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 140.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 699G",
      "code_information": [
        {
          "code": "3089354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON/MONO    ETH562H",
      "code_information": [
        {
          "code": "3089357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 CT1  J-945-H",
      "code_information": [
        {
          "code": "3089362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7.322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0        585H",
      "code_information": [
        {
          "code": "3089363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C0125",
      "code_information": [
        {
          "code": "3089364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMD2B413",
      "code_information": [
        {
          "code": "3089371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.7684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPD2B408",
      "code_information": [
        {
          "code": "3089372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       U204H",
      "code_information": [
        {
          "code": "3089379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J428H",
      "code_information": [
        {
          "code": "3089381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 46,
          "minimum": 9.66,
          "maximum": 33.6812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 33.6812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6/0 P-1    J489G",
      "code_information": [
        {
          "code": "3089382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 7-0        J488G",
      "code_information": [
        {
          "code": "3089384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPP1A400",
      "code_information": [
        {
          "code": "3089386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 370,
          "minimum": 77.7,
          "maximum": 270.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 270.914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2.0 ALL PX83Hs",
      "code_information": [
        {
          "code": "3089390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1654G",
      "code_information": [
        {
          "code": "3089394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NUROLON 4-0       C584D",
      "code_information": [
        {
          "code": "3089396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 236,
          "minimum": 49.56,
          "maximum": 172.7992,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 172.7992,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPD2B413",
      "code_information": [
        {
          "code": "3089403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 391,
          "minimum": 82.11,
          "maximum": 286.2902,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 286.2902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z493G",
      "code_information": [
        {
          "code": "3089407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN 4-0 1644G",
      "code_information": [
        {
          "code": "3089408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE RS23",
      "code_information": [
        {
          "code": "3089410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC PBT xxMM",
      "code_information": [
        {
          "code": "3089416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 498.6282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1B406",
      "code_information": [
        {
          "code": "3089420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 380,
          "minimum": 79.8,
          "maximum": 278.236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 278.236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MONOPTY 16GX20CM",
      "code_information": [
        {
          "code": "3089701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 272.3784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE EICA8875-01",
      "code_information": [
        {
          "code": "3090040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2017,
          "minimum": 423.57,
          "maximum": 1476.8474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1476.8474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-TURBINATE RED EICA4845-01",
      "code_information": [
        {
          "code": "3090049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2053,
          "minimum": 431.13,
          "maximum": 1503.2066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1503.2066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,TOPAZ MICRO ACH4041-0",
      "code_information": [
        {
          "code": "3090061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1965.957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .045      WS-1106ST",
      "code_information": [
        {
          "code": "3090191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER #2          AR-7200",
      "code_information": [
        {
          "code": "3091195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 264.3242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER 2-0         AR-7220",
      "code_information": [
        {
          "code": "3091196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 264.3242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5         310.243",
      "code_information": [
        {
          "code": "3091211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 623.8344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.8MM        292.68",
      "code_information": [
        {
          "code": "3091218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 623,
          "minimum": 130.83,
          "maximum": 456.1606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 456.1606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6MM AGK16150",
      "code_information": [
        {
          "code": "3091237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 341.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-2.5MM DRILL XFO082501",
      "code_information": [
        {
          "code": "3091238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE          1806-0080S",
      "code_information": [
        {
          "code": "3091250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1197,
          "minimum": 251.37,
          "maximum": 876.4434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 876.4434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3091317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .054          WS-1406ST",
      "code_information": [
        {
          "code": "3091319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K              0152-0218S",
      "code_information": [
        {
          "code": "3091346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 881,
          "minimum": 185.01,
          "maximum": 645.0682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 645.0682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 040-365",
      "code_information": [
        {
          "code": "3091419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1510,
          "minimum": 317.1,
          "maximum": 1105.622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1105.622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 046-072",
      "code_information": [
        {
          "code": "3091422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 357,
          "minimum": 74.97,
          "maximum": 261.3954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 261.3954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY    047-032",
      "code_information": [
        {
          "code": "3091425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 295,
          "minimum": 61.95,
          "maximum": 215.999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 215.999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE TIP      03.211.410",
      "code_information": [
        {
          "code": "3091436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 616,
          "minimum": 129.36,
          "maximum": 451.0352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 451.0352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 5.0 310.63",
      "code_information": [
        {
          "code": "3091500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3340,
          "minimum": 701.4,
          "maximum": 2445.548,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2445.548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 21665",
      "code_information": [
        {
          "code": "3091501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 73.22,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION SEID",
      "code_information": [
        {
          "code": "3091510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 890,
          "minimum": 186.9,
          "maximum": 651.658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 651.658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND M 2.5MM 03.000.007S",
      "code_information": [
        {
          "code": "3091511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 579.9024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/2X3/32 /10 3610",
      "code_information": [
        {
          "code": "3091513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 139.118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLUE-GUN CMS REVOLUTION",
      "code_information": [
        {
          "code": "3091516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1029,
          "minimum": 216.09,
          "maximum": 753.4338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 753.4338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT 5MM EB210",
      "code_information": [
        {
          "code": "3091517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1670.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT FINE EB230",
      "code_information": [
        {
          "code": "3091518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2953,
          "minimum": 620.13,
          "maximum": 2162.1866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2162.1866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE CANNU FLEX .042X12",
      "code_information": [
        {
          "code": "3091560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 412.9608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TEMPORARY CARDIA  024-100",
      "code_information": [
        {
          "code": "3091561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 159.6196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8MM FIBULA ROD 80-0642",
      "code_information": [
        {
          "code": "3091572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 956.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-FACIAL DENTAL 714-6IN-GEL",
      "code_information": [
        {
          "code": "3093187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 249,
          "minimum": 52.29,
          "maximum": 182.3178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 182.3178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ACCESSORY       3550-02",
      "code_information": [
        {
          "code": "3093195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 688.268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOBUTTON-CL ULTRA PAC 1.2",
      "code_information": [
        {
          "code": "3094000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2461,
          "minimum": 516.81,
          "maximum": 1801.9442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1801.9442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SNAPFIT 15 DEG    400152",
      "code_information": [
        {
          "code": "3102750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCL0316",
      "code_information": [
        {
          "code": "3115410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 396.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCM1545",
      "code_information": [
        {
          "code": "3115420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 396.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA ARM        420279",
      "code_information": [
        {
          "code": "3115515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA HEAD       420273",
      "code_information": [
        {
          "code": "3115525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM    420015",
      "code_information": [
        {
          "code": "3115580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT COLUMN 470341",
      "code_information": [
        {
          "code": "3115590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 206.4804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM LONG XI   470358",
      "code_information": [
        {
          "code": "3155025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 275.3072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 5MM        400161",
      "code_information": [
        {
          "code": "3170005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 8.5-13MM   420206",
      "code_information": [
        {
          "code": "3170007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA            400077",
      "code_information": [
        {
          "code": "3170010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA ENDOWRIST XI",
      "code_information": [
        {
          "code": "3170020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-8MM XI 570361",
      "code_information": [
        {
          "code": "3170050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 206.4804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL s.I.e.    410322",
      "code_information": [
        {
          "code": "3170060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.9954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL XI        480322",
      "code_information": [
        {
          "code": "3170070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.9954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUB. & FILTER 20400162S/10",
      "code_information": [
        {
          "code": "3171250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 306,
          "minimum": 64.26,
          "maximum": 224.0532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 224.0532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-ENDOWRIST STAPLER 45",
      "code_information": [
        {
          "code": "3171320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909506",
      "code_information": [
        {
          "code": "3171350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11962,
          "minimum": 2512.02,
          "maximum": 8758.5764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8758.5764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 12M OMS-T12BT",
      "code_information": [
        {
          "code": "3175750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1756,
          "minimum": 368.76,
          "maximum": 1285.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1285.7432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-SINGLE SITE 8.5    428065",
      "code_information": [
        {
          "code": "3185345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1488,
          "minimum": 312.48,
          "maximum": 1089.5136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1089.5136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEXIBLE         3100A",
      "code_information": [
        {
          "code": "3240013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1449,
          "minimum": 304.29,
          "maximum": 1060.9578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1060.9578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GENERATOR INFANT LP FLOW",
      "code_information": [
        {
          "code": "3240072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 596,
          "minimum": 125.16,
          "maximum": 436.3912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 436.3912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INFANT O2 DELIVERY   RT329",
      "code_information": [
        {
          "code": "3240073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 476,
          "minimum": 99.96,
          "maximum": 348.5272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 348.5272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RESUS S/USE       900RD010",
      "code_information": [
        {
          "code": "3240075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG HYDROGEL",
      "code_information": [
        {
          "code": "3240083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODES-EEG LOW IMPEDENCE",
      "code_information": [
        {
          "code": "3240085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTERFACE-TRACHEOSTOMY HI FLOW",
      "code_information": [
        {
          "code": "3240105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 327,
          "minimum": 68.67,
          "maximum": 239.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 239.4294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BELLOWS & WATER TRAP 3100A",
      "code_information": [
        {
          "code": "3240167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CONNECTING TUBING.   3100",
      "code_information": [
        {
          "code": "3240170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 233.5718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 6 FR    196",
      "code_information": [
        {
          "code": "3249995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.9214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 8 FR    198",
      "code_information": [
        {
          "code": "3249997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 187,
          "minimum": 39.27,
          "maximum": 136.9214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.9214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE MAC 5FR    1925",
      "code_information": [
        {
          "code": "3249998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 139.8502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE 14FR 12\\\" 220135",
      "code_information": [
        {
          "code": "3250000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 89.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT UNCUFFED",
      "code_information": [
        {
          "code": "3281990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3282370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XS      006950",
      "code_information": [
        {
          "code": "3283013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP THERAPY  \\\"ACAPELLA\\\"",
      "code_information": [
        {
          "code": "3283015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 259.1988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION  LG     006965",
      "code_information": [
        {
          "code": "3283017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 146.44,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XLG     006970",
      "code_information": [
        {
          "code": "3283018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 146.44,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUVETTE-CO2 DISP ADULT MP01062",
      "code_information": [
        {
          "code": "3284354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 144.9756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER 5MM",
      "code_information": [
        {
          "code": "3290045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL MED HIGH FLOW",
      "code_information": [
        {
          "code": "3290046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.8396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL SM HIGH FLOW",
      "code_information": [
        {
          "code": "3290047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL LG HIGH FLOW",
      "code_information": [
        {
          "code": "3290048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP           23-0757",
      "code_information": [
        {
          "code": "3290060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 222.5888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT L599-130",
      "code_information": [
        {
          "code": "3290061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT W/MR290 SINGLE",
      "code_information": [
        {
          "code": "3290062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 370,
          "minimum": 77.7,
          "maximum": 270.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 270.914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BREATHING NEONATAL",
      "code_information": [
        {
          "code": "3290074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 94.4538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-INFANT DUAL FLOW RT26",
      "code_information": [
        {
          "code": "3290077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 323.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOWMETER-PEAK          002068",
      "code_information": [
        {
          "code": "3290080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.3656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-CPAP NASAL NSC-001",
      "code_information": [
        {
          "code": "3290082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOW-CONT CYSTO GREENLYT",
      "code_information": [
        {
          "code": "3290084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP MED",
      "code_information": [
        {
          "code": "3290127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP SMALL",
      "code_information": [
        {
          "code": "3290128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOSE-AIR MODEL 205 DISP",
      "code_information": [
        {
          "code": "3290145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED SM NIV",
      "code_information": [
        {
          "code": "3290170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED MED NIV",
      "code_information": [
        {
          "code": "3290171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED LG NIV",
      "code_information": [
        {
          "code": "3290172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 42MM    RD804-10",
      "code_information": [
        {
          "code": "3290178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP AIRLIFE W/FILTER",
      "code_information": [
        {
          "code": "3290184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 83.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL XS INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 309,
          "minimum": 64.89,
          "maximum": 226.2498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 226.2498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL LG INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL MED INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 285,
          "minimum": 59.85,
          "maximum": 208.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 208.677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 308,
          "minimum": 64.68,
          "maximum": 225.5176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 225.5176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 60MM    RD806-10",
      "code_information": [
        {
          "code": "3290194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED SMALL NIV",
      "code_information": [
        {
          "code": "3290215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.2296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 221.1244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED LARGE NIV",
      "code_information": [
        {
          "code": "3290217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.2296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 169.1382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED LG NIV",
      "code_information": [
        {
          "code": "3290219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 186.711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP ALOHA ALO100",
      "code_information": [
        {
          "code": "3290220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 704,
          "minimum": 147.84,
          "maximum": 515.4688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 515.4688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOPPER-DECANNULATION SZ4",
      "code_information": [
        {
          "code": "3290354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 760,
          "minimum": 159.6,
          "maximum": 556.472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 556.472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DIRECTIONAL BALLARD  22059",
      "code_information": [
        {
          "code": "3290385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.1148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 5MM PROX",
      "code_information": [
        {
          "code": "3290400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 699,
          "minimum": 146.79,
          "maximum": 511.8078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 511.8078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY SLT UNCUFF 5MM",
      "code_information": [
        {
          "code": "3290401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 679,
          "minimum": 142.59,
          "maximum": 497.1638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 497.1638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEST-SPU ALL SZS  WRAP-SLOTTED",
      "code_information": [
        {
          "code": "3290504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 819,
          "minimum": 171.99,
          "maximum": 599.6718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 599.6718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING WHITE    PMV005",
      "code_information": [
        {
          "code": "3290506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 876,
          "minimum": 183.96,
          "maximum": 641.4072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 641.4072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING PURPLE  PMV2001",
      "code_information": [
        {
          "code": "3290508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 875,
          "minimum": 183.75,
          "maximum": 640.675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 640.675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP LPEEP",
      "code_information": [
        {
          "code": "3290509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP ADJ          2K8082",
      "code_information": [
        {
          "code": "3290515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-THERAPRESSURE     262895",
      "code_information": [
        {
          "code": "3300010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 51,
          "minimum": 10.71,
          "maximum": 37.3422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 37.3422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOFT GOODS FOR CPM UNIT",
      "code_information": [
        {
          "code": "3302945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 240.8938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA VARICEX S",
      "code_information": [
        {
          "code": "3310024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.7726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-ENDURA KIT         775410",
      "code_information": [
        {
          "code": "3310985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 110.5622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BGE   A840235",
      "code_information": [
        {
          "code": "3310986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BLACK  554617",
      "code_information": [
        {
          "code": "3310987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 114.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX RED   A840241",
      "code_information": [
        {
          "code": "3310989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.7928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 6CMX5CM",
      "code_information": [
        {
          "code": "3310991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 8CMX5CM",
      "code_information": [
        {
          "code": "3310992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 10CMX5M",
      "code_information": [
        {
          "code": "3310993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDL K 12CMX5M",
      "code_information": [
        {
          "code": "3311000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL 15CMX.4CMX2.5M",
      "code_information": [
        {
          "code": "3311010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ12 12CM",
      "code_information": [
        {
          "code": "3311075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 290,
          "minimum": 60.9,
          "maximum": 212.338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 212.338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ7 7CM",
      "code_information": [
        {
          "code": "3311076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL SOFT",
      "code_information": [
        {
          "code": "3311078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING C",
      "code_information": [
        {
          "code": "3311085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 166.2094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AID-\\\"CLEAN EASY\\\" GRIP REACH",
      "code_information": [
        {
          "code": "3311086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 205.016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING D",
      "code_information": [
        {
          "code": "3311094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 159.6196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3311107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-LG HDL      C6298-01-25",
      "code_information": [
        {
          "code": "3311117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 53,
          "minimum": 11.13,
          "maximum": 38.8066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 38.8066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3311123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 6CMX5M",
      "code_information": [
        {
          "code": "3311138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 8CMX5M RL",
      "code_information": [
        {
          "code": "3311139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.1148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-IONTOPHOR IOGEL 2971",
      "code_information": [
        {
          "code": "3311144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 80,
          "minimum": 16.8,
          "maximum": 58.576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYBRESIS PATCH",
      "code_information": [
        {
          "code": "3311150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALU 1.5X3.5 PK 2393",
      "code_information": [
        {
          "code": "3311153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ALUM LTX FREE ALL",
      "code_information": [
        {
          "code": "3311156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXERCISER-POWER GRIP HAND",
      "code_information": [
        {
          "code": "3311157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.1892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-COMFY HAND/THUMB",
      "code_information": [
        {
          "code": "3311158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 723,
          "minimum": 151.83,
          "maximum": 529.3806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 529.3806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3311161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUTRODE RND 1.25\\\"",
      "code_information": [
        {
          "code": "3311163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT OVAL PK 2\\\"X4\\\"",
      "code_information": [
        {
          "code": "3311164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.1828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-WEIGHTED EZ GRIP 920675",
      "code_information": [
        {
          "code": "3311165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELECTRODE ADULT       9050",
      "code_information": [
        {
          "code": "3311167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3311174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 186.711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT SQ PK  1.5X3.5",
      "code_information": [
        {
          "code": "3311178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.3252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT M&LGE",
      "code_information": [
        {
          "code": "3311191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARD-FOOD INVISIBLE      1115",
      "code_information": [
        {
          "code": "3311192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-TRACTION EXER ALL C5032s",
      "code_information": [
        {
          "code": "3311193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 157,
          "minimum": 32.97,
          "maximum": 114.9554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 114.9554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT S&XS",
      "code_information": [
        {
          "code": "3311194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LAVAGE    0210112000",
      "code_information": [
        {
          "code": "3311197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 504,
          "minimum": 105.84,
          "maximum": 369.0288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 369.0288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPM SOFTGOOD FOR HOME UNIT",
      "code_information": [
        {
          "code": "3311235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 240.8938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3311250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 233.5718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HIP/KNEE W/26 REACHER",
      "code_information": [
        {
          "code": "3311251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH UPPER EXTREMITY",
      "code_information": [
        {
          "code": "3311255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.1892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-ELASTO-GEL CAST/SPL  A8273",
      "code_information": [
        {
          "code": "3311340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 38.0744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3311347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3311357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-D WRIST BRACE ALL SIZES",
      "code_information": [
        {
          "code": "3311363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 115.6876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PADDING-FOAM \\\"KOMPREX\\\" SHEET",
      "code_information": [
        {
          "code": "3311369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPOON-WEIGHTED EZ GRIP 920688",
      "code_information": [
        {
          "code": "3311406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-LONG-32\\\"       A665009",
      "code_information": [
        {
          "code": "3311472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-ALUMINUM 32\\\"      4107",
      "code_information": [
        {
          "code": "3311475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 38.0744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-STANDARD 26\\\"    A80-42",
      "code_information": [
        {
          "code": "3311479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REACHER-SAMMONS PRESTON   4109",
      "code_information": [
        {
          "code": "3311480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINTING-EZEFORM 1/8”X18”X24”",
      "code_information": [
        {
          "code": "3311600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 475,
          "minimum": 99.75,
          "maximum": 347.795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 347.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELBOW NEOPRENE XL",
      "code_information": [
        {
          "code": "3311602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 121.5452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-JOINT JACK MED   A52542",
      "code_information": [
        {
          "code": "3311613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 205.7482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 6\\\"-7\\\"",
      "code_information": [
        {
          "code": "3311625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-ELBOW/KNEE ADJ 3-14",
      "code_information": [
        {
          "code": "3311701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 176.4602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT S/M A812731",
      "code_information": [
        {
          "code": "3311702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 272.3784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND COMFY LG ADULT",
      "code_information": [
        {
          "code": "3311703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 444,
          "minimum": 93.24,
          "maximum": 325.0968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 325.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT/LARGE DYNAPRO",
      "code_information": [
        {
          "code": "3311704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 546.9534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-STABILIZER WALKER ROLYAN",
      "code_information": [
        {
          "code": "3311708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 463,
          "minimum": 97.23,
          "maximum": 339.0086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 339.0086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WALKER HIGH OVATION LRG",
      "code_information": [
        {
          "code": "3311709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 401.9778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-LMB FINGER HUGGER",
      "code_information": [
        {
          "code": "3312530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 179.389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EZEFORM-ANTI MICROBIAL 564393",
      "code_information": [
        {
          "code": "3315521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 572,
          "minimum": 120.12,
          "maximum": 418.8184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 418.8184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3397811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 255.5378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PALM SHIELD RIGHT",
      "code_information": [
        {
          "code": "3397815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 94.4538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND RIGHT/MED A31228",
      "code_information": [
        {
          "code": "3397817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND LEFT MED A31227",
      "code_information": [
        {
          "code": "3397818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SINGLE SYRINGE SSS-STP-SP",
      "code_information": [
        {
          "code": "3500008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.0096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SOFTGOODS CPM        20533",
      "code_information": [
        {
          "code": "3500038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "3500087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.7726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LMA DISP ALL SZ  1250xx",
      "code_information": [
        {
          "code": "3500245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 34FR  123034",
      "code_information": [
        {
          "code": "3500275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 28F   123028",
      "code_information": [
        {
          "code": "3500280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 26FR  123026",
      "code_information": [
        {
          "code": "3500283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 30FR  123030",
      "code_information": [
        {
          "code": "3500285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 32FR  123032",
      "code_information": [
        {
          "code": "3500288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACMENT KNEE COLD L/XL",
      "code_information": [
        {
          "code": "3500410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-PED & 60MM AIRWAY",
      "code_information": [
        {
          "code": "3500786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASPIRATOR-MECONIUM HCI   N0101",
      "code_information": [
        {
          "code": "3500789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 70,
          "minimum": 14.7,
          "maximum": 51.254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-INFANT  5442160xx",
      "code_information": [
        {
          "code": "3500792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-COLLECTION 4X8 BX     9778",
      "code_information": [
        {
          "code": "3500815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0    C0135T",
      "code_information": [
        {
          "code": "3501012",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.1658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0        697H",
      "code_information": [
        {
          "code": "3501065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 FS-3  1665G",
      "code_information": [
        {
          "code": "3501070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXTERNAL CSF DRAIN INS8700",
      "code_information": [
        {
          "code": "3501130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 448,
          "minimum": 94.08,
          "maximum": 328.0256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 328.0256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC VERALNK ULTLNK500",
      "code_information": [
        {
          "code": "3501755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 666,
          "minimum": 139.86,
          "maximum": 487.6452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 487.6452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18FR5CC 0119L18",
      "code_information": [
        {
          "code": "3501790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC       6261",
      "code_information": [
        {
          "code": "3502002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EFFLUENT 5L PRISMAFLEX",
      "code_information": [
        {
          "code": "3502007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 20F30C  0167L20",
      "code_information": [
        {
          "code": "3502010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 105.4368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-TRU-CLOSE URESIL   TCS1000",
      "code_information": [
        {
          "code": "3502048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 369,
          "minimum": 77.49,
          "maximum": 270.1818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 270.1818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 400     7000LL",
      "code_information": [
        {
          "code": "3502063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST MED RIGHT 5001-0",
      "code_information": [
        {
          "code": "3502580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 119.3486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LARGE RT  5001-04",
      "code_information": [
        {
          "code": "3502590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 119.3486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-LIFEBAND FOR AUTOPULSE",
      "code_information": [
        {
          "code": "3502593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1266,
          "minimum": 265.86,
          "maximum": 926.9652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 926.9652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST X-LG LT 5001-10",
      "code_information": [
        {
          "code": "3502600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.0096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF C",
      "code_information": [
        {
          "code": "3502706",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 547,
          "minimum": 114.87,
          "maximum": 400.5134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 400.5134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-ANKLE CONTRACTURE CALF D",
      "code_information": [
        {
          "code": "3502707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 475,
          "minimum": 99.75,
          "maximum": 347.795,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 347.795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-BUNNY W/FRAME & LINER",
      "code_information": [
        {
          "code": "3502709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 351,
          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 257.0022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-LEG FULL SM 9128-01",
      "code_information": [
        {
          "code": "3502720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 345,
          "minimum": 72.45,
          "maximum": 252.609,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 252.609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3502751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 119.3486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMIN 46-62 13992000",
      "code_information": [
        {
          "code": "3503080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-HOOD ALL  0408-8xx-000",
      "code_information": [
        {
          "code": "3503348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 679,
          "minimum": 142.59,
          "maximum": 497.1638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 497.1638,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ENV INFANT   8004-01",
      "code_information": [
        {
          "code": "3503370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT ARM",
      "code_information": [
        {
          "code": "3504148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 94.4538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT BOOT",
      "code_information": [
        {
          "code": "3504149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 94.4538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER ADULT FULL LENGTH",
      "code_information": [
        {
          "code": "3504150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 89.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED ARM",
      "code_information": [
        {
          "code": "3504151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAST-FIBER PED BOOT",
      "code_information": [
        {
          "code": "3504152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MAC 3&4",
      "code_information": [
        {
          "code": "3504355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 127.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BRITEPRO SOLO MIL 2&3",
      "code_information": [
        {
          "code": "3504357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 127.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEDLE-HUBER CT INJ 19G X .75",
      "code_information": [
        {
          "code": "3504552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1.5\\\" CT\\\"",
      "code_information": [
        {
          "code": "3504553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-SURGIFOAM      100 1974",
      "code_information": [
        {
          "code": "3504663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 326,
          "minimum": 68.46,
          "maximum": 238.6972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 238.6972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CHANNELED         KVL03C",
      "code_information": [
        {
          "code": "3504905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST EZWALK XL 2001-05",
      "code_information": [
        {
          "code": "3505035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-CAST STAT ALL 2001-00s",
      "code_information": [
        {
          "code": "3505545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA TENDERWRAP 4\\\"X10YDS",
      "code_information": [
        {
          "code": "3505570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-WAFFLE  ALL SIZES    FW's",
      "code_information": [
        {
          "code": "3505575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 205.7482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2515H****",
      "code_information": [
        {
          "code": "3505815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICAL MED",
      "code_information": [
        {
          "code": "3505906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE HEAVY LARGE",
      "code_information": [
        {
          "code": "3505907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 75.4166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-CLAVICLE CHILD   3004-12",
      "code_information": [
        {
          "code": "3505955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION ATEC",
      "code_information": [
        {
          "code": "3506118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3506181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-7FR \\\"SLIC\\\"       SC-14701",
      "code_information": [
        {
          "code": "3506470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CURITY ULTRAMER 6FR  6006",
      "code_information": [
        {
          "code": "3506758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.9352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 22G   383591",
      "code_information": [
        {
          "code": "3507108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 24G   383590",
      "code_information": [
        {
          "code": "3507111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW ARTERIAL VENOUS",
      "code_information": [
        {
          "code": "3507185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.1722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3W 16F 5CC  0119L16",
      "code_information": [
        {
          "code": "3507187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 102.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 30CC ALL 123600As",
      "code_information": [
        {
          "code": "3507190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 94.4538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 12 5 165812",
      "code_information": [
        {
          "code": "3507192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 14 5 165814",
      "code_information": [
        {
          "code": "3507193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 18 5 165818",
      "code_information": [
        {
          "code": "3507195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 20 5 165820",
      "code_information": [
        {
          "code": "3507196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 22 5 165822",
      "code_information": [
        {
          "code": "3507197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 24 5 165824",
      "code_information": [
        {
          "code": "3507198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3/W 18F 0125RL18",
      "code_information": [
        {
          "code": "3507371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 260,
          "minimum": 54.6,
          "maximum": 190.372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 190.372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 20F 30C W/V  0125RL20",
      "code_information": [
        {
          "code": "3507373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 24F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 192.5686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-3/W 26F 30C W/V    125RV",
      "code_information": [
        {
          "code": "3507407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 20FR 30CC      266720",
      "code_information": [
        {
          "code": "3507665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.3252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 24FR 30CC      266724",
      "code_information": [
        {
          "code": "3507670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.6472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3CC   8887603101",
      "code_information": [
        {
          "code": "3507688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.6472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W  8F  3CC   8887603085",
      "code_information": [
        {
          "code": "3507852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-OXIMETRY 5 LUMEN  5032805",
      "code_information": [
        {
          "code": "3508302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1222,
          "minimum": 256.62,
          "maximum": 894.7484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 894.7484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SOAKER 1\\\"           PM030",
      "code_information": [
        {
          "code": "3508888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 719,
          "minimum": 150.99,
          "maximum": 526.4518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 526.4518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-20X1.5 RADIO ARTE RA04220",
      "code_information": [
        {
          "code": "3509147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 16FR  010116",
      "code_information": [
        {
          "code": "3509269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN COUDE 14FR  010114",
      "code_information": [
        {
          "code": "3509270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN STRAIGHT 18FR",
      "code_information": [
        {
          "code": "3509305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-CHEST DRAIN 9.6FR",
      "code_information": [
        {
          "code": "3509905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 189.6398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP ADJ     AA11",
      "code_information": [
        {
          "code": "3509911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.0978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3510001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COA 04273",
      "code_information": [
        {
          "code": "3510002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3510099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.0468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEX 72\\\"   DF47x-6121Z",
      "code_information": [
        {
          "code": "3510143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 105.4368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENTILATOR COAX",
      "code_information": [
        {
          "code": "3510148",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLEANSER-BODY FOAMING REMEDY",
      "code_information": [
        {
          "code": "3510305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCLIP-MEDIUM         523800",
      "code_information": [
        {
          "code": "3510401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL SMALL 710-SMAL",
      "code_information": [
        {
          "code": "3510714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL MEDIUM 710-MED",
      "code_information": [
        {
          "code": "3510715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 126.6706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK PEDI-SELE",
      "code_information": [
        {
          "code": "3510817",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERVICAL ALL SZ A11500x",
      "code_information": [
        {
          "code": "3510830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3511220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52,
          "minimum": 10.92,
          "maximum": 38.0744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 38.0744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y PRISMAFLEX",
      "code_information": [
        {
          "code": "3511240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISP F/NEOBLUE COZY",
      "code_information": [
        {
          "code": "3511668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.1658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FOOT PNEU LRG PR  VP520L",
      "code_information": [
        {
          "code": "3511672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 100.3114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-FT PNEU REGULAR PR VP520",
      "code_information": [
        {
          "code": "3511673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE LTX-FREE   610-002",
      "code_information": [
        {
          "code": "3511677",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3511958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 304,
          "minimum": 63.84,
          "maximum": 222.5888,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 222.5888,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FOAM W/COVER    154264",
      "code_information": [
        {
          "code": "3512506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 211,
          "minimum": 44.31,
          "maximum": 154.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 154.4942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 16-18FR",
      "code_information": [
        {
          "code": "3512575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 110.5622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.1CM 9231",
      "code_information": [
        {
          "code": "3512760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CIRCUMCISION 1.2CM 9232",
      "code_information": [
        {
          "code": "3512761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 95.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ANCHOR PICC LNE PIC0220",
      "code_information": [
        {
          "code": "3512770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 PED PEDI CAP",
      "code_information": [
        {
          "code": "3512773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 126.6706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RESQPOD 029-12-0242-000",
      "code_information": [
        {
          "code": "3512775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 951.86,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FEMOSTOP         11165",
      "code_information": [
        {
          "code": "3512782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 955.521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH STABILIZ    DIO120",
      "code_information": [
        {
          "code": "3512792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CATH SECURMENT VPPDFP",
      "code_information": [
        {
          "code": "3512794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL  SMALL  S-22MM",
      "code_information": [
        {
          "code": "3513121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.0978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VAGINAL MEDIUM  M-29MM",
      "code_information": [
        {
          "code": "3513123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 122.2774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-ACCU ANTI-REFLUX INS8401",
      "code_information": [
        {
          "code": "3513202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1657,
          "minimum": 347.97,
          "maximum": 1213.2554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1213.2554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST VALVE PNEUMOSTAT",
      "code_information": [
        {
          "code": "3513225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT PRATT        SU130s",
      "code_information": [
        {
          "code": "3513231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE W/ISO BAG    1003",
      "code_information": [
        {
          "code": "3513475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.1998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM SM SIMP CS",
      "code_information": [
        {
          "code": "3514025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 414,
          "minimum": 86.94,
          "maximum": 303.1308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 303.1308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GRANUFOAM BRIDGE",
      "code_information": [
        {
          "code": "3514230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 640,
          "minimum": 134.4,
          "maximum": 468.608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 468.608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-PREVENA 45ML",
      "code_information": [
        {
          "code": "3514251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 367,
          "minimum": 77.07,
          "maximum": 268.7174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 268.7174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO MED",
      "code_information": [
        {
          "code": "3514259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1213,
          "minimum": 254.73,
          "maximum": 888.1586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 888.1586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC VERAFLO SM",
      "code_information": [
        {
          "code": "3514261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYME 4X4 5044",
      "code_information": [
        {
          "code": "3514264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 40.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM     10X15CM",
      "code_information": [
        {
          "code": "3514272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 139.8502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PACING 5FR   006173P",
      "code_information": [
        {
          "code": "3514812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1649,
          "minimum": 346.29,
          "maximum": 1207.3978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1207.3978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-REDIPAK",
      "code_information": [
        {
          "code": "3514819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 210,
          "minimum": 44.1,
          "maximum": 153.762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 153.762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-PALL BLOOD        SQ40S",
      "code_information": [
        {
          "code": "3516138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.7928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTERLINE-INTUBATED SET 185",
      "code_information": [
        {
          "code": "3516160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-MR 9GX14CM 20MM",
      "code_information": [
        {
          "code": "3518855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2344,
          "minimum": 492.24,
          "maximum": 1716.2768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1716.2768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX16CM",
      "code_information": [
        {
          "code": "3518857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 419.5506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX1xCM",
      "code_information": [
        {
          "code": "3518865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 419.5506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX1xCM",
      "code_information": [
        {
          "code": "3518868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 16GX10CM",
      "code_information": [
        {
          "code": "3518870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 578,
          "minimum": 121.38,
          "maximum": 423.2116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 423.2116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-LARYNGOSCOPE DISP",
      "code_information": [
        {
          "code": "3518940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1962",
      "code_information": [
        {
          "code": "3519300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1034,
          "minimum": 217.14,
          "maximum": 757.0948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.0948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS LF ADLT",
      "code_information": [
        {
          "code": "3519395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUGGER-HEART STERNUM ALL 1000s",
      "code_information": [
        {
          "code": "3519770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 12F 36\\\"",
      "code_information": [
        {
          "code": "3520193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 95.186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 20F 5CC",
      "code_information": [
        {
          "code": "3520196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 154,
          "minimum": 32.34,
          "maximum": 112.7588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 112.7588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 22FR 20CC",
      "code_information": [
        {
          "code": "3520199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 170.6026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-INTUBATION ALL Gs",
      "code_information": [
        {
          "code": "3521014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1015,
          "minimum": 213.15,
          "maximum": 743.183,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 743.183,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ALGO HEARING TEST  040546",
      "code_information": [
        {
          "code": "3521438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 163.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BARRIER MINOR PROTECTIVE",
      "code_information": [
        {
          "code": "3521441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT FEMORAL 111644",
      "code_information": [
        {
          "code": "3521442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 426,
          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 311.9172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACOSTOMY PROC ******",
      "code_information": [
        {
          "code": "3521523",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 207,
          "minimum": 43.47,
          "maximum": 151.5654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 151.5654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH CVP SL       AK-24301",
      "code_information": [
        {
          "code": "3521655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRAINAL ACCESS    INS-5HND",
      "code_information": [
        {
          "code": "3521683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2054,
          "minimum": 431.34,
          "maximum": 1503.9388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1503.9388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DAILY CARE            6638",
      "code_information": [
        {
          "code": "3521745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAINAGE PLEURX    50-7510",
      "code_information": [
        {
          "code": "3521755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 603.3328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HYPOTHERMIA \\\"KOOL KIT\\\" 900",
      "code_information": [
        {
          "code": "3521917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1792,
          "minimum": 376.32,
          "maximum": 1312.1024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1312.1024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 6FR AK-09601***",
      "code_information": [
        {
          "code": "3521942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 407,
          "minimum": 85.47,
          "maximum": 298.0054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 298.0054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INTRODUCER 8.5 AK-09803CDC",
      "code_information": [
        {
          "code": "3521947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 628,
          "minimum": 131.88,
          "maximum": 459.8216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 459.8216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGAT CONE/TUBE BX  7721",
      "code_information": [
        {
          "code": "3521963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-SARAH 2778 ALL SIZES",
      "code_information": [
        {
          "code": "3522000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 505,
          "minimum": 106.05,
          "maximum": 369.761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 369.761,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRA-HANNAH 2160 ALL SIZES",
      "code_information": [
        {
          "code": "3522002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 256,
          "minimum": 53.76,
          "maximum": 187.4432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 187.4432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K ALL SIZES",
      "code_information": [
        {
          "code": "3522003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 210.8736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LUMBAR PUNCTURE    4011015",
      "code_information": [
        {
          "code": "3522152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.2296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MAC CATH MULTI AK-21242CDC",
      "code_information": [
        {
          "code": "3522182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1364,
          "minimum": 286.44,
          "maximum": 998.7208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 998.7208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 20FR         6820",
      "code_information": [
        {
          "code": "3522270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL 24FR M00568241",
      "code_information": [
        {
          "code": "3522271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KOOL NEONATAL 950",
      "code_information": [
        {
          "code": "3522460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1169,
          "minimum": 245.49,
          "maximum": 855.9418,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 855.9418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING ALL",
      "code_information": [
        {
          "code": "3522465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 95.186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-MORGAN LTX-FREE    MT2000",
      "code_information": [
        {
          "code": "3522687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 448,
          "minimum": 94.08,
          "maximum": 328.0256,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 328.0256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-4-WAY         4238701",
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        {
          "code": "3523121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND PREMATURE 900643",
      "code_information": [
        {
          "code": "3523139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BILIBAND MICRO     900644",
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        {
          "code": "3523140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 50MM    RD805-10",
      "code_information": [
        {
          "code": "3523187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 21.21,
          "maximum": 73.9522,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MITT-HAND CONTROL PR  M2023V-A",
      "code_information": [
        {
          "code": "3523675",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTRAOSSEOUS ORANGE",
      "code_information": [
        {
          "code": "3523854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATN     ALL 7700's",
      "code_information": [
        {
          "code": "3523864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 89.46,
          "maximum": 311.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 311.9172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX11C",
      "code_information": [
        {
          "code": "3525447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X13.8 C1616A",
      "code_information": [
        {
          "code": "3525465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 259,
          "minimum": 54.39,
          "maximum": 189.6398,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 189.6398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 15X7.8  C1610A",
      "code_information": [
        {
          "code": "3525466",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X7.8  C2010A",
      "code_information": [
        {
          "code": "3525467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "3525468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL STR 17GX4-1/2\\\"",
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        {
          "code": "3525873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS G04153",
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        {
          "code": "3525915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 179.97,
          "maximum": 627.4954,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 627.4954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-4   DJ4011X",
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        {
          "code": "3525924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 245,
          "minimum": 51.45,
          "maximum": 179.389,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 179.389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL PENCAN    333866",
      "code_information": [
        {
          "code": "3525950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX5\\\"    405148",
      "code_information": [
        {
          "code": "3525951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 89.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 22GX7\\\"    405149",
      "code_information": [
        {
          "code": "3525960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X22G",
      "code_information": [
        {
          "code": "3525975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 75.4166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-LUMBAR PUNCTURE 1\\\"X25G",
      "code_information": [
        {
          "code": "3525976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PROBLOC 20X100 HN3S-100",
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        {
          "code": "3526110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E CATH PLUS 241285-41E",
      "code_information": [
        {
          "code": "3526122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 467,
          "minimum": 98.07,
          "maximum": 341.9374,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POLYLOOP-LIGATING DEVICE HX-40",
      "code_information": [
        {
          "code": "3526123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 707.3052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-PULSAVAC 00-5150-182-00",
      "code_information": [
        {
          "code": "3526127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 129,
          "minimum": 27.09,
          "maximum": 94.4538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 94.4538,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL EXTEND 480422",
      "code_information": [
        {
          "code": "3526149",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3703,
          "minimum": 777.63,
          "maximum": 2711.3366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2711.3366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-AIRWAY EMMA 17448",
      "code_information": [
        {
          "code": "3526175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 121.5452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.5/2.8",
      "code_information": [
        {
          "code": "3526179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1520,
          "minimum": 319.2,
          "maximum": 1112.944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1112.944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO xxXxxMM 2.0",
      "code_information": [
        {
          "code": "3526182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 758.5592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 5800-8-125",
      "code_information": [
        {
          "code": "3526187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1120,
          "minimum": 235.2,
          "maximum": 820.064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 820.064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.3MM TWIST QC",
      "code_information": [
        {
          "code": "3526189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT,-NIFOMETER 10-340-03",
      "code_information": [
        {
          "code": "3526194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.2636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT GROMMET 70143061",
      "code_information": [
        {
          "code": "3526216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 186,
          "minimum": 39.06,
          "maximum": 136.1892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.1892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VENT BUTTERFLY 240073",
      "code_information": [
        {
          "code": "3526217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER SB4000SA",
      "code_information": [
        {
          "code": "3526218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1162,
          "minimum": 244.02,
          "maximum": 850.8164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 850.8164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER SB4040SC",
      "code_information": [
        {
          "code": "3526219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1298,
          "minimum": 272.58,
          "maximum": 950.3956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 950.3956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MALLEABLE MS4000SC",
      "code_information": [
        {
          "code": "3526220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1330,
          "minimum": 279.3,
          "maximum": 973.826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 973.826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y936H",
      "code_information": [
        {
          "code": "3526223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 116,
          "minimum": 24.36,
          "maximum": 84.9352,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.9352,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CANNULATED 2.0X120MM",
      "code_information": [
        {
          "code": "3526239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1136,
          "minimum": 238.56,
          "maximum": 831.7792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 831.7792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICYRL-4-0 COATED PLUS",
      "code_information": [
        {
          "code": "3526253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 76,
          "minimum": 15.96,
          "maximum": 55.6472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.6472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X36",
      "code_information": [
        {
          "code": "3526256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-1 PDS PLUS 1X96",
      "code_information": [
        {
          "code": "3526257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOPED-0 PDS PLUS 1X60",
      "code_information": [
        {
          "code": "3526258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 78.3454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VICRYL-2-0 COATED PLUS 12X18",
      "code_information": [
        {
          "code": "3526259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MONOCRYL-4-0 PLUS 1X18",
      "code_information": [
        {
          "code": "3526264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRILL 2.0 SPEED HAND WRIS",
      "code_information": [
        {
          "code": "3526271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2047.2312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM   70890830",
      "code_information": [
        {
          "code": "3526275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM ANTERIOR",
      "code_information": [
        {
          "code": "3526278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 595,
          "minimum": 124.95,
          "maximum": 435.659,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 435.659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM     70890832",
      "code_information": [
        {
          "code": "3526280",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 119,
          "minimum": 24.99,
          "maximum": 87.1318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.1318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT LMA ALL SIZE",
      "code_information": [
        {
          "code": "3526297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURAGAIN SIZE 4",
      "code_information": [
        {
          "code": "3526298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB THREADED AR-13226T",
      "code_information": [
        {
          "code": "3526314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 930,
          "minimum": 195.3,
          "maximum": 680.946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 680.946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BATTERY 1.5 50-1010",
      "code_information": [
        {
          "code": "3526343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 919,
          "minimum": 192.99,
          "maximum": 672.8918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 672.8918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL EPISTAX 10CM",
      "code_information": [
        {
          "code": "3526349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 343.4018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC SUPER AK-24301-SK",
      "code_information": [
        {
          "code": "3526356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 684,
          "minimum": 143.64,
          "maximum": 500.8248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 500.8248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-MAMMARY 351-3500SZ",
      "code_information": [
        {
          "code": "3526357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 946,
          "minimum": 198.66,
          "maximum": 692.6612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 692.6612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 115” Y 1637101",
      "code_information": [
        {
          "code": "3526361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 124,
          "minimum": 26.04,
          "maximum": 90.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.7928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHAVER CLOSED 4MM STRT",
      "code_information": [
        {
          "code": "3526366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1269,
          "minimum": 266.49,
          "maximum": 929.1618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 929.1618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-METATRSAL 20MM",
      "code_information": [
        {
          "code": "3526404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2211.244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.2X1.8X87MM",
      "code_information": [
        {
          "code": "3526414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CANN 2.2 A-2716",
      "code_information": [
        {
          "code": "3526415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2846,
          "minimum": 597.66,
          "maximum": 2083.8412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2083.8412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINAL 20GX6 405211",
      "code_information": [
        {
          "code": "3526416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL 7 SP-78107",
      "code_information": [
        {
          "code": "3526419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1023,
          "minimum": 214.83,
          "maximum": 749.0406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 749.0406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ROBOTIC SIE DYNJ905699",
      "code_information": [
        {
          "code": "3526423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1952,
          "minimum": 409.92,
          "maximum": 1429.2544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1429.2544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO SHOULDER DYNJ60141",
      "code_information": [
        {
          "code": "3526425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 561.5974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ARTHRO KNEE DYNJ60140",
      "code_information": [
        {
          "code": "3526428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 449.5708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-LOW FLOW,DISP PATIENT",
      "code_information": [
        {
          "code": "3526443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HIGH FLOW, DISP PT'",
      "code_information": [
        {
          "code": "3526445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1053,
          "minimum": 221.13,
          "maximum": 771.0066,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 771.0066,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SMALL PED NASAL OXYGEN",
      "code_information": [
        {
          "code": "3526446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-PED/ADULT SM – MP1500",
      "code_information": [
        {
          "code": "3526447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 63,
          "minimum": 13.23,
          "maximum": 46.1286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.1286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIGH FLOW ADULT MA1700",
      "code_information": [
        {
          "code": "3526449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INFANT OVER THE EAR",
      "code_information": [
        {
          "code": "3526455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORPEDO-4.0MM X13 CM AR-8400T",
      "code_information": [
        {
          "code": "3526458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 930,
          "minimum": 195.3,
          "maximum": 680.946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 680.946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ABLATOR-ASPIRATING AR-8921",
      "code_information": [
        {
          "code": "3526459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 994.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR COLD 10MM Rnd",
      "code_information": [
        {
          "code": "3526467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 281,
          "minimum": 59.01,
          "maximum": 205.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 205.7482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-OVAL FLUSH-CUT AR-8550FOS",
      "code_information": [
        {
          "code": "3526471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 576.9736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOLVE-CUT RESIST XL520036000",
      "code_information": [
        {
          "code": "3526473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 824,
          "minimum": 173.04,
          "maximum": 603.3328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 603.3328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-LABRAL WHITE/BLACK 1.5MM",
      "code_information": [
        {
          "code": "3526474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-90 DEG APOLLO AR-9811",
      "code_information": [
        {
          "code": "3526476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 994.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-ELITE IRRIG 5407010470",
      "code_information": [
        {
          "code": "3526484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 568.1872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRING-MR EMPOWERCTA",
      "code_information": [
        {
          "code": "3526487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 12 DPSB 60707010200",
      "code_information": [
        {
          "code": "3526492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 207.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPSB 60707010300",
      "code_information": [
        {
          "code": "3526493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPSB 60707010400",
      "code_information": [
        {
          "code": "3526494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.8056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 24 DPDB 60708010300",
      "code_information": [
        {
          "code": "3526495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 469,
          "minimum": 98.49,
          "maximum": 343.4018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 343.4018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TUBING MXB-T",
      "code_information": [
        {
          "code": "3526520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 506,
          "minimum": 106.26,
          "maximum": 370.4932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 370.4932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-FLOTRAX PERFUSION 84\\\" M",
      "code_information": [
        {
          "code": "3526525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2947,
          "minimum": 618.87,
          "maximum": 2157.7934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2157.7934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.5MMX13CM AR-8550EX",
      "code_information": [
        {
          "code": "3526571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 332.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BULLET CUTTING 3MM",
      "code_information": [
        {
          "code": "3526591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2519,
          "minimum": 528.99,
          "maximum": 1844.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1844.4118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-BIOPATCH CHG 1”X4MM 4150",
      "code_information": [
        {
          "code": "3526904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-JAW TISSUE ENSEAL LRG",
      "code_information": [
        {
          "code": "3526926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2829,
          "minimum": 594.09,
          "maximum": 2071.3938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2071.3938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT SMALL",
      "code_information": [
        {
          "code": "3526929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 571,
          "minimum": 119.91,
          "maximum": 418.0862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 418.0862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WHITEFOAM KIT LARGE",
      "code_information": [
        {
          "code": "3526930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 660,
          "minimum": 138.6,
          "maximum": 483.252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 483.252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A443",
      "code_information": [
        {
          "code": "3526935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 287.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX PDS SXPP1A445",
      "code_information": [
        {
          "code": "3526936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFX 2-0 SXMP1B413",
      "code_information": [
        {
          "code": "3526938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 352,
          "minimum": 73.92,
          "maximum": 257.7344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 257.7344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4FUSION 2.0 CALIBRATED",
      "code_information": [
        {
          "code": "3526943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1113,
          "minimum": 233.73,
          "maximum": 814.9386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 814.9386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-AFFINITY MANIFOLD 1S85R1",
      "code_information": [
        {
          "code": "3526965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-COMP SPEEDARC 11X15X13MM",
      "code_information": [
        {
          "code": "3526978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5134,
          "minimum": 1078.14,
          "maximum": 3759.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3759.1148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 7.5CM POST",
      "code_information": [
        {
          "code": "3526995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 608,
          "minimum": 127.68,
          "maximum": 445.1776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 445.1776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING DISP EXT 5450850003",
      "code_information": [
        {
          "code": "3526996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1879,
          "minimum": 394.59,
          "maximum": 1375.8038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1375.8038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINDER-DISP SUCT CAN",
      "code_information": [
        {
          "code": "3526997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 419,
          "minimum": 87.99,
          "maximum": 306.7918,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.7918,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIAMETER-STRAIGHT 5450800309",
      "code_information": [
        {
          "code": "3526999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3756,
          "minimum": 788.76,
          "maximum": 2750.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2750.1432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CRICOTHYROIDOTOMY EMERGENT",
      "code_information": [
        {
          "code": "3527020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1028,
          "minimum": 215.88,
          "maximum": 752.7016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 752.7016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-2.7MM 311.26",
      "code_information": [
        {
          "code": "3527056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 864,
          "minimum": 181.44,
          "maximum": 632.6208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 632.6208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.15, 1.5MM",
      "code_information": [
        {
          "code": "3527057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 606.2616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-311.19, 2.0MM",
      "code_information": [
        {
          "code": "3527058",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 849,
          "minimum": 178.29,
          "maximum": 621.6378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 621.6378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SUCTION 12.7 HI CAPACITY",
      "code_information": [
        {
          "code": "3527060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.35X50X101MM",
      "code_information": [
        {
          "code": "3527084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 758.5592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-BIOPSY MARQUEE",
      "code_information": [
        {
          "code": "3527097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 570.3838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PICK-VEIN 6541",
      "code_information": [
        {
          "code": "3527102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 2.0/2.3",
      "code_information": [
        {
          "code": "3527119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1520,
          "minimum": 319.2,
          "maximum": 1112.944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1112.944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO",
      "code_information": [
        {
          "code": "3527121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 758.5592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-BRUSH ALGER 0.5MM",
      "code_information": [
        {
          "code": "3527123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.0234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIOPATCH-DRESS CHG 1” X 7MM",
      "code_information": [
        {
          "code": "3527124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLENOID DRILL 2.5MM",
      "code_information": [
        {
          "code": "3527142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8074,
          "minimum": 1695.54,
          "maximum": 5911.7828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5911.7828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME STD WIDE MT-APUW",
      "code_information": [
        {
          "code": "3527145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 341.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLUS-VIVAER ARC DISP CAT500",
      "code_information": [
        {
          "code": "3527147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9026,
          "minimum": 1895.46,
          "maximum": 6608.8372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 6608.8372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-KEITH FREE 1827-2.5DC",
      "code_information": [
        {
          "code": "3527159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.3MM AR-8930D-13",
      "code_information": [
        {
          "code": "3527163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-GONIO SURG OSIG",
      "code_information": [
        {
          "code": "3527169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BONE 3.2X125MM GRAY",
      "code_information": [
        {
          "code": "3527179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1195,
          "minimum": 250.95,
          "maximum": 874.979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 874.979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-POSEY SECURE INFANT PED",
      "code_information": [
        {
          "code": "3527200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.8258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-INDIGO 140CM CATRXKIT",
      "code_information": [
        {
          "code": "3527201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5947.6606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPERATOR-C4 PENUMBRA SEPC4",
      "code_information": [
        {
          "code": "3527202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4654,
          "minimum": 977.34,
          "maximum": 3407.6588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3407.6588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENGINE INDIGO IAPS3",
      "code_information": [
        {
          "code": "3527203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2416,
          "minimum": 507.36,
          "maximum": 1768.9952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1768.9952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VPEP 510",
      "code_information": [
        {
          "code": "3527204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 466,
          "minimum": 97.86,
          "maximum": 341.2052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 341.2052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRVO2-TUBE CHAMBER KIT, 900PT",
      "code_information": [
        {
          "code": "3527205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 730,
          "minimum": 153.3,
          "maximum": 534.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 534.506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN W/AO 5.0MM",
      "code_information": [
        {
          "code": "3527232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 357.3136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-QUICK CONN DRVR-UQC-T10",
      "code_information": [
        {
          "code": "3527241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1399,
          "minimum": 293.79,
          "maximum": 1024.3478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1024.3478,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7X70MM IJS-CDC-2770",
      "code_information": [
        {
          "code": "3527242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2039.177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERES-PASSIVE 8801075",
      "code_information": [
        {
          "code": "3527246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.9X10X61MM",
      "code_information": [
        {
          "code": "3527253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1036,
          "minimum": 217.56,
          "maximum": 758.5592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 758.5592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DRILL SELF HOLD",
      "code_information": [
        {
          "code": "3527257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2110,
          "minimum": 443.1,
          "maximum": 1544.942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1544.942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE 108984",
      "code_information": [
        {
          "code": "3527264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 410.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO MICRO 0",
      "code_information": [
        {
          "code": "3527266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 475.1978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3527268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5424,
          "minimum": 1139.04,
          "maximum": 3971.4528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3971.4528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-STERILE PGH 396985",
      "code_information": [
        {
          "code": "3527269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 410.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-BS IS-1 330834",
      "code_information": [
        {
          "code": "3527270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 7MM, 70X",
      "code_information": [
        {
          "code": "3527281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 517.6654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-301-CG 343586",
      "code_information": [
        {
          "code": "3527282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 410.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIDER TS101DC",
      "code_information": [
        {
          "code": "3527287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 594,
          "minimum": 124.74,
          "maximum": 434.9268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 434.9268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 8CM 7089-0832",
      "code_information": [
        {
          "code": "3527289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 111,
          "minimum": 23.31,
          "maximum": 81.2742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON VENT 1.27MM",
      "code_information": [
        {
          "code": "3527290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 117.152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER DS2C026",
      "code_information": [
        {
          "code": "3527342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4316,
          "minimum": 906.36,
          "maximum": 3160.1752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3160.1752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ALLEN 3.0MM 904-0030",
      "code_information": [
        {
          "code": "3527343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 375,
          "minimum": 78.75,
          "maximum": 274.575,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 274.575,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3527395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-CALAZIME REMEDY 4 OZ",
      "code_information": [
        {
          "code": "3527567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-K SOFT 117464",
      "code_information": [
        {
          "code": "3527806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 60-S FIRM 119291",
      "code_information": [
        {
          "code": "3527807",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 410.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-S 65-C MEDIUM 342657",
      "code_information": [
        {
          "code": "3527808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-INFANT POSITIONER",
      "code_information": [
        {
          "code": "3527875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 144.2434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-INFANT FULL BODY",
      "code_information": [
        {
          "code": "3527890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1059,
          "minimum": 222.39,
          "maximum": 775.3998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 775.3998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNCK SLCT980010",
      "code_information": [
        {
          "code": "3527947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-IRR SUCT 5500-573-000",
      "code_information": [
        {
          "code": "3527977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3127,
          "minimum": 656.67,
          "maximum": 2289.5894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2289.5894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUCTION 5450-851-012",
      "code_information": [
        {
          "code": "3527978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MICRO-IQ 12CM 5500-25S-309",
      "code_information": [
        {
          "code": "3527979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5094,
          "minimum": 1069.74,
          "maximum": 3729.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3729.8268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STD-12CM 5500-25S-307",
      "code_information": [
        {
          "code": "3527980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4754,
          "minimum": 998.34,
          "maximum": 3480.8788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3480.8788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRACUDA-12CM IQ 5500-25S-310",
      "code_information": [
        {
          "code": "3527981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5201,
          "minimum": 1092.21,
          "maximum": 3808.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3808.1722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND ROYLAN RT MED",
      "code_information": [
        {
          "code": "3528086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORTHOSIS-ANKLE FOOT LG",
      "code_information": [
        {
          "code": "3528101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 704,
          "minimum": 147.84,
          "maximum": 515.4688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 515.4688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 30 DPSB 60707010500",
      "code_information": [
        {
          "code": "3529495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 272.3784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-TOURN 18 DPDB 60708010200",
      "code_information": [
        {
          "code": "3529498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 428,
          "minimum": 89.88,
          "maximum": 313.3816,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 313.3816,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST DOUBLE DRY SUCTION",
      "code_information": [
        {
          "code": "3533159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 468,
          "minimum": 98.28,
          "maximum": 342.6696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 342.6696,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #4     4DCP",
      "code_information": [
        {
          "code": "3533309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION #6,8,10 DCP",
      "code_information": [
        {
          "code": "3533315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SKIN TEMP DISP MU11228",
      "code_information": [
        {
          "code": "3533577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.0468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TEMP ISOLETTE    MU12551",
      "code_information": [
        {
          "code": "3533578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 238,
          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.2636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-RECTAL/ESOPH ST     491B",
      "code_information": [
        {
          "code": "3533590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTANT-SKIN REMEDY 2 OZ",
      "code_information": [
        {
          "code": "3536085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-SKIN NO STING    MSC1528",
      "code_information": [
        {
          "code": "3536099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.9724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-EYE FOAM       28300",
      "code_information": [
        {
          "code": "3536100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3539345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INITIATION BREAST MILK 673",
      "code_information": [
        {
          "code": "3539346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 356,
          "minimum": 74.76,
          "maximum": 260.6632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 260.6632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-BIS QUATTRO    186-0106",
      "code_information": [
        {
          "code": "3541300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 336,
          "minimum": 70.56,
          "maximum": 246.0192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 246.0192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS PED DISP",
      "code_information": [
        {
          "code": "3541324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX LNCS ADLT DISP",
      "code_information": [
        {
          "code": "3541325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-SKIN HNICU38",
      "code_information": [
        {
          "code": "3541328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 39.5388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RECIP PLATELET     4C-2100",
      "code_information": [
        {
          "code": "3541430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 117.152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD FILTRATION   4020005",
      "code_information": [
        {
          "code": "3541446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.3656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH ARROW RADIAL ARTERY",
      "code_information": [
        {
          "code": "3541912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DISP Y FOR BLOOD IV  D-100",
      "code_information": [
        {
          "code": "3541945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 852,
          "minimum": 178.92,
          "maximum": 623.8344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 623.8344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DIALYZER EXELTRA    5M2119",
      "code_information": [
        {
          "code": "3541947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 292,
          "minimum": 61.32,
          "maximum": 213.8024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 213.8024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3541950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1539,
          "minimum": 323.19,
          "maximum": 1126.8558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1126.8558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FEMORAL ART  C-PMS-401J-FA",
      "code_information": [
        {
          "code": "3542127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO ALL SZ W/ STABILIZER",
      "code_information": [
        {
          "code": "3542128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1489,
          "minimum": 312.69,
          "maximum": 1090.2458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1090.2458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER HF 1000 PRISMAFLEX",
      "code_information": [
        {
          "code": "3542131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2248,
          "minimum": 472.08,
          "maximum": 1645.9856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1645.9856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION OSTOMY BX 1500H",
      "code_information": [
        {
          "code": "3542454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PCA 110 INFUSION 1635101",
      "code_information": [
        {
          "code": "3542760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 130,
          "minimum": 27.3,
          "maximum": 95.186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 95.186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRISMAFLEX TPE2000 114093",
      "code_information": [
        {
          "code": "3542806",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2271,
          "minimum": 476.91,
          "maximum": 1662.8262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1662.8262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-RADIAL ARTERY C-PMS-301-RA",
      "code_information": [
        {
          "code": "3543008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORACENTESIS      4653-48",
      "code_information": [
        {
          "code": "3543530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 80.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-Y TUR IRRIGATION  06543-01",
      "code_information": [
        {
          "code": "3543551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-CGLIDE XL REPOSITION",
      "code_information": [
        {
          "code": "3543685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 579.9024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE SM   2042-01",
      "code_information": [
        {
          "code": "3543730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHOE-POST OP MALE LRG  2042-03",
      "code_information": [
        {
          "code": "3543732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-NIPPLE REGULAR   67203S",
      "code_information": [
        {
          "code": "3544003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SEQ COMP KNEE      95xx",
      "code_information": [
        {
          "code": "3544619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 152.2976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501B",
      "code_information": [
        {
          "code": "3544638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.8332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE PRVP501L",
      "code_information": [
        {
          "code": "3544639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 167,
          "minimum": 35.07,
          "maximum": 122.2774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 122.2774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP KNEE   VP501M",
      "code_information": [
        {
          "code": "3544640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 148,
          "minimum": 31.08,
          "maximum": 108.3656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.3656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530M",
      "code_information": [
        {
          "code": "3544645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.8332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PNEU COMP THIGH  VP530L",
      "code_information": [
        {
          "code": "3544650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 165.4772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-ARM ELEVATOR     8011-02",
      "code_information": [
        {
          "code": "3544860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.0096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-SWATHE PED       9007-00",
      "code_information": [
        {
          "code": "3545177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 3L   5B9858",
      "code_information": [
        {
          "code": "3545500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 539,
          "minimum": 113.19,
          "maximum": 394.6558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 394.6558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 3L  5B9859",
      "code_information": [
        {
          "code": "3545502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 557,
          "minimum": 116.97,
          "maximum": 407.8354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 407.8354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 4.25% 2L  5B9896",
      "code_information": [
        {
          "code": "3545504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 366.8322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIALYSIS 2.5% 2L   5B9876",
      "code_information": [
        {
          "code": "3545505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 325.829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-DIAL 1.5% 3L       5B9857",
      "code_information": [
        {
          "code": "3545515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 529,
          "minimum": 111.09,
          "maximum": 387.3338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 387.3338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-GYLCINE 1.5% IRRIG 3000ML",
      "code_information": [
        {
          "code": "3545747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 206,
          "minimum": 43.26,
          "maximum": 150.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.8332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML  07972-08",
      "code_information": [
        {
          "code": "3545751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 153.0298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 3000ML 07828-08",
      "code_information": [
        {
          "code": "3545752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 153.0298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-LRS IRRIG 1000ML 07953-09",
      "code_information": [
        {
          "code": "3545755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-MDI ADAPTER INLINE",
      "code_information": [
        {
          "code": "3545901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.0MM 2883-02-040",
      "code_information": [
        {
          "code": "3547925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3717.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-BENDING 03.501.072",
      "code_information": [
        {
          "code": "3547929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1032,
          "minimum": 216.72,
          "maximum": 755.6304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 755.6304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 650.010",
      "code_information": [
        {
          "code": "3547941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM 60XL",
      "code_information": [
        {
          "code": "3547946",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 494.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MIXER-CEMENT 3CC 658.969S",
      "code_information": [
        {
          "code": "3547948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.601S",
      "code_information": [
        {
          "code": "3547949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2211.244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-ULTRA ACCESS 658.902S",
      "code_information": [
        {
          "code": "3547952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5359,
          "minimum": 1125.39,
          "maximum": 3923.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3923.8598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VAC M6275009/10",
      "code_information": [
        {
          "code": "3547958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 122,
          "minimum": 25.62,
          "maximum": 89.3284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 89.3284,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-QUILL 2-0 YA-2034Q",
      "code_information": [
        {
          "code": "3547961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 336,
          "minimum": 70.56,
          "maximum": 246.0192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 246.0192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-4-0 PROLENE 8526H",
      "code_information": [
        {
          "code": "3547969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 90,
          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT",
      "code_information": [
        {
          "code": "3547970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 494.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX",
      "code_information": [
        {
          "code": "3547971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 398,
          "minimum": 83.58,
          "maximum": 291.4156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 291.4156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY UNCUFF",
      "code_information": [
        {
          "code": "3547972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 421.7472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 2MM AR-7523",
      "code_information": [
        {
          "code": "3547986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-ZONE NAVIGATOR AR-7900",
      "code_information": [
        {
          "code": "3547987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM 650.112",
      "code_information": [
        {
          "code": "3547990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX CN",
      "code_information": [
        {
          "code": "3547997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 488,
          "minimum": 102.48,
          "maximum": 357.3136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 357.3136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY FLEX UN",
      "code_information": [
        {
          "code": "3547998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 402,
          "minimum": 84.42,
          "maximum": 294.3444,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 294.3444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SHILEY",
      "code_information": [
        {
          "code": "3547999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY CUFFED",
      "code_information": [
        {
          "code": "3548000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 671,
          "minimum": 140.91,
          "maximum": 491.3062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 491.3062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED  4LPC",
      "code_information": [
        {
          "code": "3548001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 626,
          "minimum": 131.46,
          "maximum": 458.3572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 458.3572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ4 S",
      "code_information": [
        {
          "code": "3548003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 88.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-TRACH 15MM DECANN WHITE",
      "code_information": [
        {
          "code": "3548004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-TRACH SZ 1 DECANN SH",
      "code_information": [
        {
          "code": "3548005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 40.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED",
      "code_information": [
        {
          "code": "3548006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 780,
          "minimum": 163.8,
          "maximum": 571.116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 571.116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY FLEX INNER",
      "code_information": [
        {
          "code": "3548007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER SPARE SZ1",
      "code_information": [
        {
          "code": "3548009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 121,
          "minimum": 25.41,
          "maximum": 88.5962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 88.5962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FLUENT DISP FLT-112",
      "code_information": [
        {
          "code": "3548028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1739,
          "minimum": 365.19,
          "maximum": 1273.2958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1273.2958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MOMOPTY 20X15 21201",
      "code_information": [
        {
          "code": "3549005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 458,
          "minimum": 96.18,
          "maximum": 335.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 335.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEELIFT-AFO  081531532",
      "code_information": [
        {
          "code": "3549018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 842,
          "minimum": 176.82,
          "maximum": 616.5124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 616.5124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-SUCTION NEURO NST031/25",
      "code_information": [
        {
          "code": "3549020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-SHANK MOD 5",
      "code_information": [
        {
          "code": "3549027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2211.244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-LORDOTIC 5",
      "code_information": [
        {
          "code": "3549030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1719.9378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KVLAB3C",
      "code_information": [
        {
          "code": "3549037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-KING CHANNELED KCLAB2C",
      "code_information": [
        {
          "code": "3549038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.9926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-OPEN 279726500",
      "code_information": [
        {
          "code": "3549047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3029,
          "minimum": 636.09,
          "maximum": 2217.8338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2217.8338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX ER VALVE REPLACEMEN",
      "code_information": [
        {
          "code": "3549059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 410.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX CATH ACCESS 50-7280",
      "code_information": [
        {
          "code": "3549060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-NAVIGATION 286750210S",
      "code_information": [
        {
          "code": "3549063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1965.957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CONCAVE 020 XFR004xxx",
      "code_information": [
        {
          "code": "3549066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2903,
          "minimum": 609.63,
          "maximum": 2125.5766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2125.5766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LENS-IOL SND1T3 20.5",
      "code_information": [
        {
          "code": "3549069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3696.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAND-SYNC DISTAL RADIAL, SDRB-",
      "code_information": [
        {
          "code": "3549082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 297.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-BASIC HEEL PRESSURE",
      "code_information": [
        {
          "code": "3549107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 246.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- LIGHT 03.612.021S",
      "code_information": [
        {
          "code": "3549135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2191,
          "minimum": 460.11,
          "maximum": 1604.2502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1604.2502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LIGHT 03.615.132S",
      "code_information": [
        {
          "code": "3549136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1748,
          "minimum": 367.08,
          "maximum": 1279.8856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1279.8856,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 388.175",
      "code_information": [
        {
          "code": "3549150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1078,
          "minimum": 226.38,
          "maximum": 789.3116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 789.3116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 9-0 V449G",
      "code_information": [
        {
          "code": "3549155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 161.084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHALANGEAL 20MM",
      "code_information": [
        {
          "code": "3549160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2211.244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADER-TRIAL DRG 7032ANS",
      "code_information": [
        {
          "code": "3549166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1965.957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULAIDE-CPAP SIZE 2, CA102-",
      "code_information": [
        {
          "code": "3549182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 121.5452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL PRP ABS-10061T",
      "code_information": [
        {
          "code": "3549185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1596.9282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.021S",
      "code_information": [
        {
          "code": "3549190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2362,
          "minimum": 496.02,
          "maximum": 1729.4564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1729.4564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 703713",
      "code_information": [
        {
          "code": "3549201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1238.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TAP 12.5MM 338.17",
      "code_information": [
        {
          "code": "3549204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2673,
          "minimum": 561.33,
          "maximum": 1957.1706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1957.1706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL- CANN 6.5MM 702603",
      "code_information": [
        {
          "code": "3549216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2032,
          "minimum": 426.72,
          "maximum": 1487.8304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1487.8304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CSG WORLEY STANDARD",
      "code_information": [
        {
          "code": "3549218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1900,
          "minimum": 399,
          "maximum": 1391.18,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1391.18,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-LAT VEIN WORLEY",
      "code_information": [
        {
          "code": "3549219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2264,
          "minimum": 475.44,
          "maximum": 1657.7008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1657.7008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-UNCUFFED 7.0 70XLTUP",
      "code_information": [
        {
          "code": "3549227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 676,
          "minimum": 141.96,
          "maximum": 494.9672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 494.9672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 2.1X87 A-3836",
      "code_information": [
        {
          "code": "3549229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-PCL 2.4MMX10",
      "code_information": [
        {
          "code": "3549231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1003.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-CROSS PLATE 705172",
      "code_information": [
        {
          "code": "3549243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2762,
          "minimum": 580.02,
          "maximum": 2022.3364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2022.3364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-ANGEL CPRP ABS-10063",
      "code_information": [
        {
          "code": "3549250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1449.756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-THREAD LOCK 03.835.009S",
      "code_information": [
        {
          "code": "3549252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1698,
          "minimum": 356.58,
          "maximum": 1243.2756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1243.2756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPEEDGUIDE-T8 2.4/2.7X30MM",
      "code_information": [
        {
          "code": "3549269",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2408,
          "minimum": 505.68,
          "maximum": 1763.1376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1763.1376,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEEDGUIDE AO 2.0X30MM",
      "code_information": [
        {
          "code": "3549270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5577,
          "minimum": 1171.17,
          "maximum": 4083.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4083.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 2.1MM",
      "code_information": [
        {
          "code": "3549272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1742,
          "minimum": 365.82,
          "maximum": 1275.4924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1275.4924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS TRIPLE 91429",
      "code_information": [
        {
          "code": "3549278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 453,
          "minimum": 95.13,
          "maximum": 331.6866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 331.6866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.1X300MM RMT3130",
      "code_information": [
        {
          "code": "3549279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2423,
          "minimum": 508.83,
          "maximum": 1774.1206,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1774.1206,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-2.5 SOLID HT-2502",
      "code_information": [
        {
          "code": "3549283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1101.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Y-PORT-20 FR M00580641",
      "code_information": [
        {
          "code": "3549284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 93.7216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-DHS REAMER 338.13",
      "code_information": [
        {
          "code": "3549287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7319,
          "minimum": 1536.99,
          "maximum": 5358.9718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5358.9718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOAM-BUMP 10X6X6\\\" DYNJBUMP03",
      "code_information": [
        {
          "code": "3549293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 161,
          "minimum": 33.81,
          "maximum": 117.8842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 117.8842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-PALM ROLYAN SOFT GEL LT",
      "code_information": [
        {
          "code": "3549295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 246,
          "minimum": 51.66,
          "maximum": 180.1212,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 180.1212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FORCEP SUCTION 9G12R",
      "code_information": [
        {
          "code": "3549304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HUMIDIFIER ATSVII BE-1010",
      "code_information": [
        {
          "code": "3549307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CATH LINE 020378801",
      "code_information": [
        {
          "code": "3549311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM 6149.1035",
      "code_information": [
        {
          "code": "3549338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 14MM 650.114",
      "code_information": [
        {
          "code": "3549348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL ANGLE 14MM 684.434",
      "code_information": [
        {
          "code": "3549349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2211.244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5M SHORT 6149.1037",
      "code_information": [
        {
          "code": "3549352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 16MM 650.116",
      "code_information": [
        {
          "code": "3549372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 955.521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD BK-IS 109185",
      "code_information": [
        {
          "code": "3549411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 410.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP 2.4MM",
      "code_information": [
        {
          "code": "3549451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 329,
          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 240.8938,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB LARGE AR-8970-09",
      "code_information": [
        {
          "code": "3549452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1032.402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-ADAPTER BIOPSY MAJ-1414",
      "code_information": [
        {
          "code": "3549507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUICKCLOT 8X8 4010",
      "code_information": [
        {
          "code": "3549703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 762.2202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-COMFY FINGER",
      "code_information": [
        {
          "code": "3549716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 102,
          "minimum": 21.42,
          "maximum": 74.6844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 74.6844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 6 6SIC",
      "code_information": [
        {
          "code": "3549725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.0606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER DISP SIZE 8 8SIC",
      "code_information": [
        {
          "code": "3549726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.0606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-QUIKCLOT 5X5 4000",
      "code_information": [
        {
          "code": "3549730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 733,
          "minimum": 153.93,
          "maximum": 536.7026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 536.7026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOCN0346",
      "code_information": [
        {
          "code": "3549731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 560.133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 200 AC-10030100",
      "code_information": [
        {
          "code": "3549732",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3289,
          "minimum": 690.69,
          "maximum": 2408.2058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2408.2058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ESOPHAGEAL 100001",
      "code_information": [
        {
          "code": "3549734",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-BV175-6 BLUE EPM8743",
      "code_information": [
        {
          "code": "3549735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 607,
          "minimum": 127.47,
          "maximum": 444.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 444.4454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-MOSES 365 AC-10030110",
      "code_information": [
        {
          "code": "3549736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1892.0048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-LONG TUNNELING SC-4254",
      "code_information": [
        {
          "code": "3549742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1474.6508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM 03.010.061",
      "code_information": [
        {
          "code": "3549747",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1751,
          "minimum": 367.71,
          "maximum": 1282.0822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1282.0822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 16MM 03.037.002",
      "code_information": [
        {
          "code": "3549748",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5189,
          "minimum": 1089.69,
          "maximum": 3799.3858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3799.3858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 6-9MM 03.037.022",
      "code_information": [
        {
          "code": "3549750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3479,
          "minimum": 730.59,
          "maximum": 2547.3238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2547.3238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-BABYFLOW PLUS S DISP MP37",
      "code_information": [
        {
          "code": "3549751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-DISP",
      "code_information": [
        {
          "code": "3549752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 130.3316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEOMASK-CPAP",
      "code_information": [
        {
          "code": "3549753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 143.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BABUFLOE SZ 4 DISP MP0149",
      "code_information": [
        {
          "code": "3549754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 225,
          "minimum": 47.25,
          "maximum": 164.745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP",
      "code_information": [
        {
          "code": "3549755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 180,
          "minimum": 37.8,
          "maximum": 131.796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PNEUMOTHORAX G05297",
      "code_information": [
        {
          "code": "3549757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1013,
          "minimum": 212.73,
          "maximum": 741.7186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 741.7186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOURNIQUET-TACTICAL 30-0023",
      "code_information": [
        {
          "code": "3549759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 360,
          "minimum": 75.6,
          "maximum": 263.592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 263.592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R001",
      "code_information": [
        {
          "code": "3549765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1892.0048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-A003",
      "code_information": [
        {
          "code": "3549766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2334.2536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-SEATTLE PLUS MP02260",
      "code_information": [
        {
          "code": "3549776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 412.9608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE HINGED DONJOY",
      "code_information": [
        {
          "code": "3549781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 872,
          "minimum": 183.12,
          "maximum": 638.4784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 638.4784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-DISTAL 24MM 03.211.024",
      "code_information": [
        {
          "code": "3549786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1933.008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PROX 24MM 03.211.124",
      "code_information": [
        {
          "code": "3549787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2640,
          "minimum": 554.4,
          "maximum": 1933.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1933.008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ORISE GEL SINGLE PK 1",
      "code_information": [
        {
          "code": "3549805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 726.3424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROCESSOR-SOUND LINE 90711",
      "code_information": [
        {
          "code": "3549810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-BAHA STORAGE Z342010",
      "code_information": [
        {
          "code": "3549811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-PERFORM REV PERI MWJ126",
      "code_information": [
        {
          "code": "3549818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5X220MM DWD017",
      "code_information": [
        {
          "code": "3549819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 950,
          "minimum": 199.5,
          "maximum": 695.59,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 695.59,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-0xx-000",
      "code_information": [
        {
          "code": "3549839",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SHAFT 8X510 0227-8510S",
      "code_information": [
        {
          "code": "3549851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1867,
          "minimum": 392.07,
          "maximum": 1367.0174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1367.0174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LOCKING 705078",
      "code_information": [
        {
          "code": "3549854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1563,
          "minimum": 328.23,
          "maximum": 1144.4286,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1144.4286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 700354",
      "code_information": [
        {
          "code": "3549867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1228,
          "minimum": 257.88,
          "maximum": 899.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 899.1416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW INFINITY 3600315",
      "code_information": [
        {
          "code": "3549870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 917.4466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT- DRILL 2.4 G3606010",
      "code_information": [
        {
          "code": "3549873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-STRAIGH TIP 2762-01-0004",
      "code_information": [
        {
          "code": "3549916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2310.091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DILATOR NIM 945NSD2750",
      "code_information": [
        {
          "code": "3549918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAGITTAL 2296-003-155",
      "code_information": [
        {
          "code": "3549927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 2.4 1608-006-147",
      "code_information": [
        {
          "code": "3549928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 751,
          "minimum": 157.71,
          "maximum": 549.8822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 549.8822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-DIAMOND 1MM 1608-006-151",
      "code_information": [
        {
          "code": "3549929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 722,
          "minimum": 151.62,
          "maximum": 528.6484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 528.6484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-413S1",
      "code_information": [
        {
          "code": "3549931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 7X15MM 2296-003-103",
      "code_information": [
        {
          "code": "3549932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 521,
          "minimum": 109.41,
          "maximum": 381.4762,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 381.4762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MICRO SAG 2296-003-111S5",
      "code_information": [
        {
          "code": "3549933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 388,
          "minimum": 81.48,
          "maximum": 284.0936,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.0936,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SHORT 2.5MM 2296-003-413",
      "code_information": [
        {
          "code": "3549934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 366.8322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48X70MM 2108-197-00S4",
      "code_information": [
        {
          "code": "3549935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 226,
          "minimum": 47.46,
          "maximum": 165.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 165.4772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X75MM 4125-089-075",
      "code_information": [
        {
          "code": "3549936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 737,
          "minimum": 154.77,
          "maximum": 539.6314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 539.6314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 13X90MM 4113-119-090",
      "code_information": [
        {
          "code": "3549938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 438.5878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-119-090",
      "code_information": [
        {
          "code": "3549939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 561.5974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 4125-127-090",
      "code_information": [
        {
          "code": "3549940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 767,
          "minimum": 161.07,
          "maximum": 561.5974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 561.5974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-70X12.5MM 0277-096-277",
      "code_information": [
        {
          "code": "3549941",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 572,
          "minimum": 120.12,
          "maximum": 418.8184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 418.8184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RECIPR. 0277-096-325",
      "code_information": [
        {
          "code": "3549942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 583,
          "minimum": 122.43,
          "maximum": 426.8726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 426.8726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG 25X90MM 6125-119-090",
      "code_information": [
        {
          "code": "3549943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 832,
          "minimum": 174.72,
          "maximum": 609.1904,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 609.1904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-18.5X90.5 2108-382-003",
      "code_information": [
        {
          "code": "3549944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 618,
          "minimum": 129.78,
          "maximum": 452.4996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 452.4996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE,SAW VASC 5400-134-415",
      "code_information": [
        {
          "code": "3549951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 685,
          "minimum": 143.85,
          "maximum": 501.557,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 501.557,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE, SAW 25X90MM 6725-127-09",
      "code_information": [
        {
          "code": "3549952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2047,
          "minimum": 429.87,
          "maximum": 1498.8134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1498.8134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 8MM M0013635",
      "code_information": [
        {
          "code": "3549961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4128,
          "minimum": 866.88,
          "maximum": 3022.5216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3022.5216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SPINAL W/EPI & BUPIV 3338",
      "code_information": [
        {
          "code": "3549962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 280,
          "minimum": 58.8,
          "maximum": 205.016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 205.016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-VISTASEAL VSTL35",
      "code_information": [
        {
          "code": "3549965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 819,
          "minimum": 171.99,
          "maximum": 599.6718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 599.6718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SUTURE UCL AR-7715-4.5",
      "code_information": [
        {
          "code": "3549968",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3921,
          "minimum": 823.41,
          "maximum": 2870.9562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2870.9562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CEMENT MIX 0206-015-000",
      "code_information": [
        {
          "code": "3549999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 564,
          "minimum": 118.44,
          "maximum": 412.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 412.9608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-75MM 00-5901-020-00",
      "code_information": [
        {
          "code": "3550017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2485,
          "minimum": 521.85,
          "maximum": 1819.517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1819.517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-TIB 42-5320-064-02",
      "code_information": [
        {
          "code": "3550019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1952.16,
          "maximum": 6806.5312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 6806.5312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-REVERSED GLEN MWJ004",
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        {
          "code": "3550025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1474.6508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-PRESS FIT REV DWJ002",
      "code_information": [
        {
          "code": "3550026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1965.957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-INTERLOCKING 3MMX4CM M001",
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        {
          "code": "3550029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2529,
          "minimum": 531.09,
          "maximum": 1851.7338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1851.7338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DSIP RFID EXPIRATORY MP0",
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        {
          "code": "3550040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.6X30 SPEED 703894",
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        {
          "code": "3550046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 937,
          "minimum": 196.77,
          "maximum": 686.0714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 686.0714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC D-BLADE",
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        {
          "code": "3550048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #3 MILLER",
      "code_information": [
        {
          "code": "3550049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 177.1924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WALKER-CAM  II 55988503",
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        {
          "code": "3550050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 762.9524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-2.5X7MM AR-8998DS",
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        {
          "code": "3550061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1522.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 PC-5",
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        {
          "code": "3550066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0 18\\\" PC-3",
      "code_information": [
        {
          "code": "3550067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROS-NASAL SEPTAL ROUND SP1102",
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        {
          "code": "3550072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1351.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-DRIVER 05.000.007.01S",
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        {
          "code": "3550083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2060,
          "minimum": 432.6,
          "maximum": 1508.332,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST ALL SIZE 9105-00s",
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        {
          "code": "3550085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP LRG 47800100",
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        {
          "code": "3550087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1425.5934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP REG 47700100",
      "code_information": [
        {
          "code": "3550088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1253.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP SLIM 4760010",
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        {
          "code": "3550089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1253.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CAN 190MM 03.010.036",
      "code_information": [
        {
          "code": "3550091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3373,
          "minimum": 708.33,
          "maximum": 2469.7106,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2469.7106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-W/F L&L PED ALL 5002s",
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        {
          "code": "3550092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 18.9,
          "maximum": 65.898,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 65.898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION 6MMX10CM M00",
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        {
          "code": "3550094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 531.09,
          "maximum": 1851.7338,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1851.7338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-ANNULOTOMY 675.405S",
      "code_information": [
        {
          "code": "3550111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1965.957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-SHIM SS 6133.0326S",
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        {
          "code": "3550112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-BRILL 3.5 682.108S",
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        {
          "code": "3550131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 332.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FILLER DELIVERY 658.914S",
      "code_information": [
        {
          "code": "3550136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3717.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CT 3.5M 6149.9135",
      "code_information": [
        {
          "code": "3550137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 726.3424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DIABETIC FOOT CARE 0811748",
      "code_information": [
        {
          "code": "3550156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREWDRIVER 71MM 705506",
      "code_information": [
        {
          "code": "3550158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1223,
          "minimum": 256.83,
          "maximum": 895.4806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 895.4806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X25MM 7005-3325",
      "code_information": [
        {
          "code": "3550159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT RSZ4001S",
      "code_information": [
        {
          "code": "3550168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1449.756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SCREW 1020-00-000",
      "code_information": [
        {
          "code": "3550179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NOVOSTITCH PRO CTX-C001",
      "code_information": [
        {
          "code": "3550198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1032.402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN 22GX9CM",
      "code_information": [
        {
          "code": "3550200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 297.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.8X122 A-3738",
      "code_information": [
        {
          "code": "3550221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIMED RX COUDE 1314ANS",
      "code_information": [
        {
          "code": "3550227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CERV MOBI-C 13X17 MB3375",
      "code_information": [
        {
          "code": "3550228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21902,
          "minimum": 4599.42,
          "maximum": 16036.6444,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 16036.6444,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPAR 14MM 0024-LDR",
      "code_information": [
        {
          "code": "3550229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1474.6508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-OXYGEN VOCSN PRT-00930",
      "code_information": [
        {
          "code": "3550231",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 287.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-TORQUE 2.5MM 694",
      "code_information": [
        {
          "code": "3550236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5953,
          "minimum": 1250.13,
          "maximum": 4358.7866,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4358.7866,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-T 601.800",
      "code_information": [
        {
          "code": "3550239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3487,
          "minimum": 732.27,
          "maximum": 2553.1814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2553.1814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPANNER-WRENCH 687.509",
      "code_information": [
        {
          "code": "3550240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INSERTER 694.004",
      "code_information": [
        {
          "code": "3550241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4175,
          "minimum": 876.75,
          "maximum": 3056.935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3056.935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-INSERTER 694.005",
      "code_information": [
        {
          "code": "3550242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4231,
          "minimum": 888.51,
          "maximum": 3097.9382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3097.9382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-CALIBER GRAPHIC 994.001",
      "code_information": [
        {
          "code": "3550244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14166,
          "minimum": 2974.86,
          "maximum": 10372.3452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10372.3452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARGYLE SHUNT 8888577775",
      "code_information": [
        {
          "code": "3550249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 305.3274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND A31216",
      "code_information": [
        {
          "code": "3550250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 364.6356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-MEPITEL 6.8X10",
      "code_information": [
        {
          "code": "3550253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 139.8502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 12FR 1.0CM",
      "code_information": [
        {
          "code": "3550256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 703.6442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-I/A CAPSULGUARD",
      "code_information": [
        {
          "code": "3550264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 195.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE RT SM 70831",
      "code_information": [
        {
          "code": "3550272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 338,
          "minimum": 70.98,
          "maximum": 247.4836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 247.4836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND DELUXE LT SM 70831",
      "code_information": [
        {
          "code": "3550273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 259.1988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-OSTEOFUZE OF-BMA-11",
      "code_information": [
        {
          "code": "3550274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8800,
          "minimum": 1848,
          "maximum": 6443.36,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 6443.36,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX RD SET REUSE",
      "code_information": [
        {
          "code": "3550275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 870,
          "minimum": 182.7,
          "maximum": 637.014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 637.014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-HEMOSTATIC POWDER 1978",
      "code_information": [
        {
          "code": "3550278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 541.828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARTRIDGE-NOVOSTITCH CTX-R002",
      "code_information": [
        {
          "code": "3550306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2584,
          "minimum": 542.64,
          "maximum": 1892.0048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1892.0048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TROCAR THORACIC 24FR SWD",
      "code_information": [
        {
          "code": "3550314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.2328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-INSPIRA BREAST SRM",
      "code_information": [
        {
          "code": "3550331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4485,
          "minimum": 941.85,
          "maximum": 3283.917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3283.917,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP 180-210CC",
      "code_information": [
        {
          "code": "3550332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-DEFENDO Y-OPSY 100303",
      "code_information": [
        {
          "code": "3550394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.1658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PUSHLOCK 2.9MM",
      "code_information": [
        {
          "code": "3550395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 842.7622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM",
      "code_information": [
        {
          "code": "3550396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1358,
          "minimum": 285.18,
          "maximum": 994.3276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 994.3276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH 8MM 100/897/080",
      "code_information": [
        {
          "code": "3550399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 878,
          "minimum": 184.38,
          "maximum": 642.8716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 642.8716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER 8MM 100/890/080",
      "code_information": [
        {
          "code": "3550400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 18FR 897518",
      "code_information": [
        {
          "code": "3550406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 195,
          "minimum": 40.95,
          "maximum": 142.779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-TRIPLE NEEDLE INS-5300",
      "code_information": [
        {
          "code": "3550411",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4172,
          "minimum": 876.12,
          "maximum": 3054.7384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3054.7384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPIN W/ADAPTER INS-5910",
      "code_information": [
        {
          "code": "3550414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4906,
          "minimum": 1030.26,
          "maximum": 3592.1732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3592.1732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J556G",
      "code_information": [
        {
          "code": "3550419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 183,
          "minimum": 38.43,
          "maximum": 133.9926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.9926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0 770G",
      "code_information": [
        {
          "code": "3550420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 200,
          "minimum": 42,
          "maximum": 146.44,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 146.44,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8695G",
      "code_information": [
        {
          "code": "3550421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STATLOCK-URO FOLEY FOL0105",
      "code_information": [
        {
          "code": "3550423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-REDDIE KNEE XL 08154723",
      "code_information": [
        {
          "code": "3550426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 319.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-BACK ROLYANFIT MESH",
      "code_information": [
        {
          "code": "3550427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 267,
          "minimum": 56.07,
          "maximum": 195.4974,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 195.4974,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-2.3MM PED SCREW 4008-00",
      "code_information": [
        {
          "code": "3550429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER",
      "code_information": [
        {
          "code": "3550432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 472.269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING RS5200",
      "code_information": [
        {
          "code": "3550447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5472,
          "minimum": 1149.12,
          "maximum": 4006.5984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4006.5984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-FIXATION LG FP9000L",
      "code_information": [
        {
          "code": "3550448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 428.337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL",
      "code_information": [
        {
          "code": "3550461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 727.8068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-PRIME 286750200S",
      "code_information": [
        {
          "code": "3550473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1965.957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-MMG 2862-02-108",
      "code_information": [
        {
          "code": "3550480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1175,
          "minimum": 246.75,
          "maximum": 860.335,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 860.335,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MMG STEM 2862-02-204",
      "code_information": [
        {
          "code": "3550481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1719.9378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 03.010.060",
      "code_information": [
        {
          "code": "3550483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1814,
          "minimum": 380.94,
          "maximum": 1328.2108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1328.2108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-120",
      "code_information": [
        {
          "code": "3550487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 737.3254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-120LP",
      "code_information": [
        {
          "code": "3550488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 702.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MACY BEDSIDE DELIVERY M",
      "code_information": [
        {
          "code": "3550498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 932,
          "minimum": 195.72,
          "maximum": 682.4104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 682.4104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PRESSURE OPAQUE 50P148",
      "code_information": [
        {
          "code": "3550499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH,MALE EXTERNAL",
      "code_information": [
        {
          "code": "3550511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH PEDIATRIC",
      "code_information": [
        {
          "code": "3550515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO CF DEL FGS-0635",
      "code_information": [
        {
          "code": "3550530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2212,
          "minimum": 464.52,
          "maximum": 1619.6264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1619.6264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM ST 6149.1036S",
      "code_information": [
        {
          "code": "3550541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 726.3424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT CALF XL MDS601BD",
      "code_information": [
        {
          "code": "3550555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 148.6366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT MED MDS620",
      "code_information": [
        {
          "code": "3550556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 257,
          "minimum": 53.97,
          "maximum": 188.1754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 188.1754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT FOOT LRG MDS620L",
      "code_information": [
        {
          "code": "3550557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 277,
          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.8194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH MED MDS630MD",
      "code_information": [
        {
          "code": "3550558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 351,
          "minimum": 73.71,
          "maximum": 257.0022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 257.0022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH LRG MDS630LD",
      "code_information": [
        {
          "code": "3550559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-DVT THIGH X-LG MDS630BD",
      "code_information": [
        {
          "code": "3550560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 383,
          "minimum": 80.43,
          "maximum": 280.4326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 280.4326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT 10° TIP MLD-0068",
      "code_information": [
        {
          "code": "3550592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2310.091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.5X350MM PK6 MLD-0301",
      "code_information": [
        {
          "code": "3550593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 872.0502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-8/13/18MM MLD-0441S",
      "code_information": [
        {
          "code": "3550594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3614.1392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIM-SPIKE BLUNT MLD-0513",
      "code_information": [
        {
          "code": "3550595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1873,
          "minimum": 393.33,
          "maximum": 1371.4106,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1371.4106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP- DILATOR MLD-0345",
      "code_information": [
        {
          "code": "3550596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 872.0502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153207",
      "code_information": [
        {
          "code": "3550599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-THORACIC TGMR312610",
      "code_information": [
        {
          "code": "3550613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84847,
          "minimum": 17817.87,
          "maximum": 62124.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62124.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.2X12MM 03.501.762",
      "code_information": [
        {
          "code": "3550619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2487,
          "minimum": 522.27,
          "maximum": 1820.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1820.9814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX16CM",
      "code_information": [
        {
          "code": "3550630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 573,
          "minimum": 120.33,
          "maximum": 419.5506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 419.5506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX16CM",
      "code_information": [
        {
          "code": "3550631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-PEDICAL SCREW 3603-00-TE",
      "code_information": [
        {
          "code": "3550634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PEDIATRIC YG-232T",
      "code_information": [
        {
          "code": "3550638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 221.1244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT LARGE YG-282T",
      "code_information": [
        {
          "code": "3550639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 191,
          "minimum": 40.11,
          "maximum": 139.8502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 139.8502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-DRAINAGE 4000CC 153509",
      "code_information": [
        {
          "code": "3550645",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-2/W 10FR 3ML 165810",
      "code_information": [
        {
          "code": "3550646",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 56,
          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.0032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-MARKING ROBOTIP INFARED",
      "code_information": [
        {
          "code": "3550649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SYRINGE F/MRI SQK65VS",
      "code_information": [
        {
          "code": "3550657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 166.2094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE,FLEX FLEX-200-QFT",
      "code_information": [
        {
          "code": "3550658",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 0200-20",
      "code_information": [
        {
          "code": "3550659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1013.3648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W COUDE 24F 5CC 0",
      "code_information": [
        {
          "code": "3550665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 170,
          "minimum": 35.7,
          "maximum": 124.474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 124.474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ASSEMBLY DISP 83030-1",
      "code_information": [
        {
          "code": "3550668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1576,
          "minimum": 330.96,
          "maximum": 1153.9472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1153.9472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY 18G ANG 221251",
      "code_information": [
        {
          "code": "3550683",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 149,
          "minimum": 31.29,
          "maximum": 109.0978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.0978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-BONE 3.8X13CM AR-8380BC",
      "code_information": [
        {
          "code": "3550684",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 576.9736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VS-1 5FR 80CM BEACON TIP",
      "code_information": [
        {
          "code": "3550691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL DETACHMENT RH1",
      "code_information": [
        {
          "code": "3550699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1170.0556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE D9212",
      "code_information": [
        {
          "code": "3550703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1077,
          "minimum": 226.17,
          "maximum": 788.5794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 788.5794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SMARTRELEASE ONYX 83030-",
      "code_information": [
        {
          "code": "3550710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1969,
          "minimum": 413.49,
          "maximum": 1441.7018,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1441.7018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM 2.3MM 2862-02-201",
      "code_information": [
        {
          "code": "3550713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3171,
          "minimum": 665.91,
          "maximum": 2321.8062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2321.8062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-PROBE ULTRASOUND 8’ CVC6",
      "code_information": [
        {
          "code": "3550720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 169,
          "minimum": 35.49,
          "maximum": 123.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.7418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BONE HARVEST 03.404.000S",
      "code_information": [
        {
          "code": "3550737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12726,
          "minimum": 2672.46,
          "maximum": 9317.9772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 9317.9772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MENISCAL ROOT 71935068",
      "code_information": [
        {
          "code": "3550740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5252,
          "minimum": 1102.92,
          "maximum": 3845.5144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3845.5144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-REAMER",
      "code_information": [
        {
          "code": "3550752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3893,
          "minimum": 817.53,
          "maximum": 2850.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2850.4546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXY ADULT ETCO2 OM-2125-8",
      "code_information": [
        {
          "code": "3550753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-OXYTYKE INFNT W/7’ TUBING",
      "code_information": [
        {
          "code": "3550754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-BAYONET 188MM 1563-00",
      "code_information": [
        {
          "code": "3550760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1474.6508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT INTERSTIM 3560022",
      "code_information": [
        {
          "code": "3550762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1631,
          "minimum": 342.51,
          "maximum": 1194.2182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1194.2182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 3MM BIT DK-300",
      "code_information": [
        {
          "code": "3550765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2326,
          "minimum": 488.46,
          "maximum": 1703.0972,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1703.0972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DECOMPRESSION ZZ-0056",
      "code_information": [
        {
          "code": "3550777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 127.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,LASER TRACH",
      "code_information": [
        {
          "code": "3550778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ILLUMINATION 675.725S",
      "code_information": [
        {
          "code": "3550783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5947.6606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP THR 1.35M",
      "code_information": [
        {
          "code": "3550793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.1956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0 8762H",
      "code_information": [
        {
          "code": "3550794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (15) 8800966",
      "code_information": [
        {
          "code": "3550803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERE-PASSIVE (5) 8801002",
      "code_information": [
        {
          "code": "3550804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 337,
          "minimum": 70.77,
          "maximum": 246.7514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 246.7514,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAN 4.6X220 P99-110-4622",
      "code_information": [
        {
          "code": "3550805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1591,
          "minimum": 334.11,
          "maximum": 1164.9302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1164.9302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110MM 213524",
      "code_information": [
        {
          "code": "3550809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 945,
          "minimum": 198.45,
          "maximum": 691.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 691.929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-STIM ADJ 2862-02-200",
      "code_information": [
        {
          "code": "3550815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3171,
          "minimum": 665.91,
          "maximum": 2321.8062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2321.8062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.1X50 M-R 01-7141",
      "code_information": [
        {
          "code": "3550816",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1472,
          "minimum": 309.12,
          "maximum": 1077.7984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1077.7984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-COIL EMBOLIZATION PODH1",
      "code_information": [
        {
          "code": "3550822",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1170.0556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4.0 AO A-8004.03",
      "code_information": [
        {
          "code": "3550830",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1879,
          "minimum": 394.59,
          "maximum": 1375.8038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1375.8038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 16FR PEDS 8016",
      "code_information": [
        {
          "code": "3550842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CLEARCUT 5X13 AR-8500COS",
      "code_information": [
        {
          "code": "3550848",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 576.9736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.45MM SM 45303145",
      "code_information": [
        {
          "code": "3550850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAGE-12MM/8° 50/18 LUI81249",
      "code_information": [
        {
          "code": "3550854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 19856,
          "minimum": 4169.76,
          "maximum": 14538.5632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 14538.5632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-CUSTOM MED PK623984",
      "code_information": [
        {
          "code": "3550856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 52648,
          "minimum": 11056.08,
          "maximum": 38548.8656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 38548.8656,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BAL RX DC-RYxxxxxx",
      "code_information": [
        {
          "code": "3550857",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-R2P MISAGO SXRxxxxxx",
      "code_information": [
        {
          "code": "3550858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4415,
          "minimum": 927.15,
          "maximum": 3232.663,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3232.663,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-METACROSS BD-xxxxxxxx",
      "code_information": [
        {
          "code": "3550859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1850,
          "minimum": 388.5,
          "maximum": 1354.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1354.57,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-EXT F/2.16MM 3560030",
      "code_information": [
        {
          "code": "3550864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-INTERPULSE",
      "code_information": [
        {
          "code": "3550869",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 117.152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-SKULL MOUNT 9735300",
      "code_information": [
        {
          "code": "3550873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1643,
          "minimum": 345.03,
          "maximum": 1203.0046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1203.0046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16FR A3",
      "code_information": [
        {
          "code": "3550876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 437,
          "minimum": 91.77,
          "maximum": 319.9714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 319.9714,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.0X150MM 705234",
      "code_information": [
        {
          "code": "3550888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 903,
          "minimum": 189.63,
          "maximum": 661.1766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 661.1766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-PERFORATED FUNCTIONAL 0",
      "code_information": [
        {
          "code": "3550898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 210.8736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-HI-SPEED 4X11 1884068HS",
      "code_information": [
        {
          "code": "3550911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2381,
          "minimum": 500.01,
          "maximum": 1743.3682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1743.3682,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-PROLAPSE HEM3335",
      "code_information": [
        {
          "code": "3550912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2317,
          "minimum": 486.57,
          "maximum": 1696.5074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1696.5074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM XT SIGTRSB60AXT",
      "code_information": [
        {
          "code": "3550915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3076,
          "minimum": 645.96,
          "maximum": 2252.2472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2252.2472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM MT SIGTRSB60AMT",
      "code_information": [
        {
          "code": "3550916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1867.8422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3551250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT  STR 35R",
      "code_information": [
        {
          "code": "3552730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.0606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3552731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKING-COMPRESSION CUSTOM",
      "code_information": [
        {
          "code": "3553701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 599,
          "minimum": 125.79,
          "maximum": 438.5878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 438.5878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STIMULATOR-BONE",
      "code_information": [
        {
          "code": "3554025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9164,
          "minimum": 1924.44,
          "maximum": 6709.8808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 6709.8808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CLAVICAL ADULT ALL 3001s",
      "code_information": [
        {
          "code": "3554085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.1148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
      "code_information": [
        {
          "code": "3554974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XXL",
      "code_information": [
        {
          "code": "3554981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 305.3274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-1/2\\\"X2\\\" SMALL    1955",
      "code_information": [
        {
          "code": "3555059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 348,
          "minimum": 73.08,
          "maximum": 254.8056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.8056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2\\\"X14\\\" LARGE     1951",
      "code_information": [
        {
          "code": "3555109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 792,
          "minimum": 166.32,
          "maximum": 579.9024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 579.9024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-2 X 3 MEDIUM     1953",
      "code_information": [
        {
          "code": "3555158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 489,
          "minimum": 102.69,
          "maximum": 358.0458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.0458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP MED  202549",
      "code_information": [
        {
          "code": "3555307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORY-W STRAP LG   202636",
      "code_information": [
        {
          "code": "3555315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUSPENSORIE-XLGE 202612&201352",
      "code_information": [
        {
          "code": "3555323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 493,
          "minimum": 103.53,
          "maximum": 360.9746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 360.9746,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       G121H",
      "code_information": [
        {
          "code": "3555374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0 FS-2   636H",
      "code_information": [
        {
          "code": "3555390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7.322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-DEXON           7618-41",
      "code_information": [
        {
          "code": "3556875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 43,
          "minimum": 9.03,
          "maximum": 31.4846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 31.4846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0   1663H",
      "code_information": [
        {
          "code": "3557098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 41,
          "minimum": 8.61,
          "maximum": 30.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 30.0202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0             678G",
      "code_information": [
        {
          "code": "3557628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7.322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 6-0 P1       697G",
      "code_information": [
        {
          "code": "3557898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0        990H",
      "code_information": [
        {
          "code": "3558678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0           685G",
      "code_information": [
        {
          "code": "3558679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 16,
          "minimum": 3.36,
          "maximum": 11.7152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 11.7152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1653-G",
      "code_information": [
        {
          "code": "3558947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1663-H",
      "code_information": [
        {
          "code": "3558970",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 49,
          "minimum": 10.29,
          "maximum": 35.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 35.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON 3-0       1669H",
      "code_information": [
        {
          "code": "3558982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4.5MM 080-453",
      "code_information": [
        {
          "code": "3559003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE P99-930-2108",
      "code_information": [
        {
          "code": "3559011",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3368,
          "minimum": 707.28,
          "maximum": 2466.0496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2466.0496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND 2.5MM 1882569HS",
      "code_information": [
        {
          "code": "3559015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1938,
          "minimum": 406.98,
          "maximum": 1419.0036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1419.0036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       G695G",
      "code_information": [
        {
          "code": "3559030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON          1696-G",
      "code_information": [
        {
          "code": "3559036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM MT SIGTRSB45AMT",
      "code_information": [
        {
          "code": "3559071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2310,
          "minimum": 485.1,
          "maximum": 1691.382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1691.382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIXATOR-LONG 4.2MM 703545",
      "code_information": [
        {
          "code": "3559085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3448,
          "minimum": 724.08,
          "maximum": 2524.6256,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2524.6256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-5X100MM FIX UNVCA5STF",
      "code_information": [
        {
          "code": "3559095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 156,
          "minimum": 32.76,
          "maximum": 114.2232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 114.2232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 15MM ONB15STF",
      "code_information": [
        {
          "code": "3559096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 325.829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-W/CANNULA 5MM ONB5STF",
      "code_information": [
        {
          "code": "3559097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 286,
          "minimum": 60.06,
          "maximum": 209.4092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 209.4092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-LARYN MILLER",
      "code_information": [
        {
          "code": "3559115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 105.4368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 12FR 0200-12L",
      "code_information": [
        {
          "code": "3559117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1013.3648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM CDH29P",
      "code_information": [
        {
          "code": "3559120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2660,
          "minimum": 558.6,
          "maximum": 1947.652,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1947.652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR",
      "code_information": [
        {
          "code": "3559142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2143,
          "minimum": 450.03,
          "maximum": 1569.1046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1569.1046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-15MM XTHICK SIG60AXT",
      "code_information": [
        {
          "code": "3559150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1896,
          "minimum": 398.16,
          "maximum": 1388.2512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1388.2512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1065832",
      "code_information": [
        {
          "code": "3559158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN GUARD",
      "code_information": [
        {
          "code": "3559160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1980.601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLLEVE-SPIN GUARD",
      "code_information": [
        {
          "code": "3559161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1702,
          "minimum": 357.42,
          "maximum": 1246.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1246.2044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYDROGEL EEG",
      "code_information": [
        {
          "code": "3559175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 40.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J493H",
      "code_information": [
        {
          "code": "3559178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0 1635G",
      "code_information": [
        {
          "code": "3559179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0 J670G",
      "code_information": [
        {
          "code": "3559180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 132.5282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP497G",
      "code_information": [
        {
          "code": "3559181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 185,
          "minimum": 38.85,
          "maximum": 135.457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 135.457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPREADER-SILIPOS GEL TOE MED",
      "code_information": [
        {
          "code": "3559185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-12MM 10*/MD 08.815.242S",
      "code_information": [
        {
          "code": "3559197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 23165,
          "minimum": 4864.65,
          "maximum": 16961.413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 16961.413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW-ACC BONCH AF541",
      "code_information": [
        {
          "code": "3559228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELBOW,STD BLUE AF541 73-112096",
      "code_information": [
        {
          "code": "3559229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM/MED/LG",
      "code_information": [
        {
          "code": "3559240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 189,
          "minimum": 39.69,
          "maximum": 138.3858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 138.3858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LAMINARIA-#4 MED 60MM 021004",
      "code_information": [
        {
          "code": "3559244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.2MM XS 45303125",
      "code_information": [
        {
          "code": "3559246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD 4033A",
      "code_information": [
        {
          "code": "3559253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X40MM 7005-3340",
      "code_information": [
        {
          "code": "3559254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.3X60MM 7005-3360",
      "code_information": [
        {
          "code": "3559255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 10G 0306-530-000",
      "code_information": [
        {
          "code": "3559260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 642,
          "minimum": 134.82,
          "maximum": 470.0724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 470.0724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ TRANS 0909-400-500",
      "code_information": [
        {
          "code": "3559261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 512.54,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CEMENT 1025-011-500",
      "code_information": [
        {
          "code": "3559262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2367,
          "minimum": 497.07,
          "maximum": 1733.1174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1733.1174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CEMENT 0306-410-000",
      "code_information": [
        {
          "code": "3559263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 604,
          "minimum": 126.84,
          "maximum": 442.2488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 442.2488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INDIGO SEP12",
      "code_information": [
        {
          "code": "3559264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8101,
          "minimum": 1701.21,
          "maximum": 5931.5522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5931.5522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURRETTE-10G 0306-621-000",
      "code_information": [
        {
          "code": "3559265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3257,
          "minimum": 683.97,
          "maximum": 2384.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2384.7754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FLEX CUFFED",
      "code_information": [
        {
          "code": "3559271",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 750,
          "minimum": 157.5,
          "maximum": 549.15,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 549.15,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-FLEXIBLE 2.9MM 682.622",
      "code_information": [
        {
          "code": "3559276",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1474.6508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ELECTRO DISP E2516H",
      "code_information": [
        {
          "code": "3559281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 104,
          "minimum": 21.84,
          "maximum": 76.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COILED 60\\\" CT 100113",
      "code_information": [
        {
          "code": "3559287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-GPS 3.5MM 6143.2572",
      "code_information": [
        {
          "code": "3559291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2211.244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4.2X360/SM 1320-3642S",
      "code_information": [
        {
          "code": "3559293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 702.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383593",
      "code_information": [
        {
          "code": "3559297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 114,
          "minimum": 23.94,
          "maximum": 83.4708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 83.4708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON BLK 4-0   1854G",
      "code_information": [
        {
          "code": "3559366",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 PC-1  1855G",
      "code_information": [
        {
          "code": "3559390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-TURB SHAVER 4MM SB4000SA",
      "code_information": [
        {
          "code": "3559391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1162,
          "minimum": 244.02,
          "maximum": 850.8164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 850.8164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 3-SPRING 19F L",
      "code_information": [
        {
          "code": "3559394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCESS 8MM",
      "code_information": [
        {
          "code": "3559395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 939,
          "minimum": 197.19,
          "maximum": 687.5358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 687.5358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FIBERLASE CO2",
      "code_information": [
        {
          "code": "3559407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3717.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0/PC-3  1865G",
      "code_information": [
        {
          "code": "3559425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MIC J FEDDING 8200",
      "code_information": [
        {
          "code": "3559430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1013.3648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT SINGLE 5' RT219",
      "code_information": [
        {
          "code": "3559433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 377,
          "minimum": 79.17,
          "maximum": 276.0394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 276.0394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT DUAL HTDRT380",
      "code_information": [
        {
          "code": "3559434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 386,
          "minimum": 81.06,
          "maximum": 282.6292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 282.6292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 EPM8706",
      "code_information": [
        {
          "code": "3559435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 814,
          "minimum": 170.94,
          "maximum": 596.0108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 596.0108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT OPEN EB240",
      "code_information": [
        {
          "code": "3559437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1670.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 2X315MM 703561",
      "code_information": [
        {
          "code": "3559445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 364.6356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VIZISNOT2 19G",
      "code_information": [
        {
          "code": "3559447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2067,
          "minimum": 434.07,
          "maximum": 1513.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1513.4574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-HIP 8.5X110 72200436",
      "code_information": [
        {
          "code": "3559448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X56MM 03.130.202",
      "code_information": [
        {
          "code": "3559456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.100",
      "code_information": [
        {
          "code": "3559462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 K-WIRE",
      "code_information": [
        {
          "code": "3559463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 994,
          "minimum": 208.74,
          "maximum": 727.8068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 727.8068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT,DRILL 22X10MM 03.501.760",
      "code_information": [
        {
          "code": "3559485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2487,
          "minimum": 522.27,
          "maximum": 1820.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1820.9814,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2590S",
      "code_information": [
        {
          "code": "3559495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 207.9448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PASSIVE MARKER 6143.2591S",
      "code_information": [
        {
          "code": "3559496",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 284,
          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 207.9448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM GPS 6143.2580S",
      "code_information": [
        {
          "code": "3559499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1351.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5MM GPS 6143.2582S",
      "code_information": [
        {
          "code": "3559500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1351.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5MM GPS 6143.2584S",
      "code_information": [
        {
          "code": "3559501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1351.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 8FR G00980",
      "code_information": [
        {
          "code": "3559527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-6MM BALT 110135",
      "code_information": [
        {
          "code": "3559542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 710,
          "minimum": 149.1,
          "maximum": 519.862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 519.862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 116239",
      "code_information": [
        {
          "code": "3559543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1039,
          "minimum": 218.19,
          "maximum": 760.7558,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 760.7558,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-OVASSAPIAN 85MM BD6075",
      "code_information": [
        {
          "code": "3559545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/55 STANDARD 7607",
      "code_information": [
        {
          "code": "3559546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2974,
          "minimum": 624.54,
          "maximum": 2177.5628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2177.5628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-LASER OMNIGUIDE 8340050",
      "code_information": [
        {
          "code": "3559560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9498,
          "minimum": 1994.58,
          "maximum": 6954.4356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 6954.4356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y3/8X3/16X3/16 10518",
      "code_information": [
        {
          "code": "3559582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-CABLE 323.1090",
      "code_information": [
        {
          "code": "3559590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1886,
          "minimum": 396.06,
          "maximum": 1380.9292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1380.9292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-BRAD POINT 4MM 323.010",
      "code_information": [
        {
          "code": "3559591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2034,
          "minimum": 427.14,
          "maximum": 1489.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1489.2948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRIPLE LUMEN 5.5FR",
      "code_information": [
        {
          "code": "3559593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1240,
          "minimum": 260.4,
          "maximum": 907.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 907.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL LUMEN 4FR",
      "code_information": [
        {
          "code": "3559594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1190,
          "minimum": 249.9,
          "maximum": 871.318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 871.318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 4.5X15 9009-2001",
      "code_information": [
        {
          "code": "3559598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3360,
          "minimum": 705.6,
          "maximum": 2460.192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2460.192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-45MM XT SIGTRSB45AXT",
      "code_information": [
        {
          "code": "3559607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2514,
          "minimum": 527.94,
          "maximum": 1840.7508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1840.7508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/F P01-900-1902",
      "code_information": [
        {
          "code": "3559612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1980.601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 19/M P01-900-1903",
      "code_information": [
        {
          "code": "3559613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1980.601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FEE-UTILIZATION PER CASE",
      "code_information": [
        {
          "code": "3559626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4344,
          "minimum": 912.24,
          "maximum": 3180.6768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3180.6768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV",
      "code_information": [
        {
          "code": "3559628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 4.0MM 705360",
      "code_information": [
        {
          "code": "3559634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1250,
          "minimum": 262.5,
          "maximum": 915.25,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 915.25,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASO 12FR",
      "code_information": [
        {
          "code": "3559651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 165,
          "minimum": 34.65,
          "maximum": 120.813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A435",
      "code_information": [
        {
          "code": "3559659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 287.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWRIST 2.5MM 60-25326",
      "code_information": [
        {
          "code": "3559663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 814.2064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC #4 051114-10",
      "code_information": [
        {
          "code": "3559671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 177.1924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN C-MAC",
      "code_information": [
        {
          "code": "3559672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 341,
          "minimum": 71.61,
          "maximum": 249.6802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 249.6802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 3.5X65",
      "code_information": [
        {
          "code": "3559673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1828,
          "minimum": 383.88,
          "maximum": 1338.4616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1338.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CURETTE-0* TIP TDC005",
      "code_information": [
        {
          "code": "3559688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2181,
          "minimum": 458.01,
          "maximum": 1596.9282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1596.9282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-0* TIP NAVIGATION",
      "code_information": [
        {
          "code": "3559690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1449.756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON SILK    C-021-",
      "code_information": [
        {
          "code": "3560079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PS-2/4-0   J496G",
      "code_information": [
        {
          "code": "3560474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J492G",
      "code_information": [
        {
          "code": "3560778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.7726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETH VICRYL 4-0  J-496-H",
      "code_information": [
        {
          "code": "3560879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.1998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-497-G",
      "code_information": [
        {
          "code": "3560893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHICON         J-774-D",
      "code_information": [
        {
          "code": "3561255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.9384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J762D",
      "code_information": [
        {
          "code": "3561415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.0468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y496G",
      "code_information": [
        {
          "code": "3562112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 92,
          "minimum": 19.32,
          "maximum": 67.3624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 67.3624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0      Y494G",
      "code_information": [
        {
          "code": "3562131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS-2    1666",
      "code_information": [
        {
          "code": "3562141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 40,
          "minimum": 8.4,
          "maximum": 29.288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 29.288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8619G",
      "code_information": [
        {
          "code": "3562217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 4-0       8699G",
      "code_information": [
        {
          "code": "3562235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 86,
          "minimum": 18.06,
          "maximum": 62.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.9692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-PACK DUAL EMPOWERCTA",
      "code_information": [
        {
          "code": "3566380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CRANIAL ACCESS  INSHITH",
      "code_information": [
        {
          "code": "3566755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2554,
          "minimum": 536.34,
          "maximum": 1870.0388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1870.0388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MULTI PODUS 9274-56XX",
      "code_information": [
        {
          "code": "3566785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 982,
          "minimum": 206.22,
          "maximum": 719.0204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 719.0204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-NURSING SUPPLEMENTAL",
      "code_information": [
        {
          "code": "3566790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.1148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FECAL MANAGEMENT",
      "code_information": [
        {
          "code": "3566823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1240,
          "minimum": 260.4,
          "maximum": 907.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 907.928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-REPLACEMENT FECAL MGMT",
      "code_information": [
        {
          "code": "3566824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3567605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 921,
          "minimum": 193.41,
          "maximum": 674.3562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 674.3562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "THERMOSET-INJECTATE    4142403",
      "code_information": [
        {
          "code": "3568123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 8.0MM",
      "code_information": [
        {
          "code": "3568561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 325.829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 6.0MM",
      "code_information": [
        {
          "code": "3568562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 450,
          "minimum": 94.5,
          "maximum": 329.49,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 329.49,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3568563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 325.829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU CUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 508,
          "minimum": 106.68,
          "maximum": 371.9576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 371.9576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BLU UNCUFF FEN 10.0MM",
      "code_information": [
        {
          "code": "3568565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAK 4  4259105",
      "code_information": [
        {
          "code": "3568757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 380,
          "minimum": 79.8,
          "maximum": 278.236,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 278.236,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-NEONATAL   42634-05",
      "code_information": [
        {
          "code": "3568760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXISENSOR-PEDIATRIC D20",
      "code_information": [
        {
          "code": "3568762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 160.3518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565200",
      "code_information": [
        {
          "code": "3569240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 829.5826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH DIALYSIS     5565150",
      "code_information": [
        {
          "code": "3569242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1133,
          "minimum": 237.93,
          "maximum": 829.5826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 829.5826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 16 FR",
      "code_information": [
        {
          "code": "3569250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 366,
          "minimum": 76.86,
          "maximum": 267.9852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 267.9852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18 FR",
      "code_information": [
        {
          "code": "3569252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 366,
          "minimum": 76.86,
          "maximum": 267.9852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 267.9852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH URETHRAL BARD 772415",
      "code_information": [
        {
          "code": "3569258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20,
          "minimum": 4.2,
          "maximum": 14.644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 14.644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-ESOPH TRACH     5-18541",
      "code_information": [
        {
          "code": "3569601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1095,
          "minimum": 229.95,
          "maximum": 801.759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.759,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY CATH/DRN BAG 6176LL",
      "code_information": [
        {
          "code": "3569779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG 16FR   6146LL",
      "code_information": [
        {
          "code": "3569805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/ BAG 18FR  6148LL",
      "code_information": [
        {
          "code": "3569853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 107,
          "minimum": 22.47,
          "maximum": 78.3454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 78.3454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/BAG LTX 16F 6165L",
      "code_information": [
        {
          "code": "3569870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-LUMB PUNC PED   4304C****",
      "code_information": [
        {
          "code": "3570330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PARA/PUD PHARMASEAL 4540A",
      "code_information": [
        {
          "code": "3570603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 117,
          "minimum": 24.57,
          "maximum": 85.6674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 6.0F",
      "code_information": [
        {
          "code": "3570605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 972,
          "minimum": 204.12,
          "maximum": 711.6984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 711.6984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PERICARDIOCENTESIS 8.3F",
      "code_information": [
        {
          "code": "3570610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1211,
          "minimum": 254.31,
          "maximum": 886.6942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 886.6942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SINGLE TAP BLOCK SPEC015",
      "code_information": [
        {
          "code": "3570640",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 687,
          "minimum": 144.27,
          "maximum": 503.0214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 503.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-NICU UMBILICAL CATH",
      "code_information": [
        {
          "code": "3570745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 543,
          "minimum": 114.03,
          "maximum": 397.5846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 397.5846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-DRESSING CHANGE 4D",
      "code_information": [
        {
          "code": "3571200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 184,
          "minimum": 38.64,
          "maximum": 134.7248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 134.7248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-THORACENTESIS CURITY 5014*",
      "code_information": [
        {
          "code": "3571304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 282,
          "minimum": 59.22,
          "maximum": 206.4804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 206.4804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 16FR 0100-16LV",
      "code_information": [
        {
          "code": "3571985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING W/ST 10F 43\\\"",
      "code_information": [
        {
          "code": "3571990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 115.6876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 8.0     86552",
      "code_information": [
        {
          "code": "3572176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 234.304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 6LPC",
      "code_information": [
        {
          "code": "3572189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 743,
          "minimum": 156.03,
          "maximum": 544.0246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 544.0246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 6CFS",
      "code_information": [
        {
          "code": "3572191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 6MM",
      "code_information": [
        {
          "code": "3572195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 507,
          "minimum": 106.47,
          "maximum": 371.2254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 371.2254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRP MIC-KEY 14FR 1.5CM",
      "code_information": [
        {
          "code": "3572305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1007,
          "minimum": 211.47,
          "maximum": 737.3254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 737.3254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 35FR     125135",
      "code_information": [
        {
          "code": "3572307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 508.1468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 39FR     125139",
      "code_information": [
        {
          "code": "3572309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 508.1468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 41FR     125141",
      "code_information": [
        {
          "code": "3572311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 694,
          "minimum": 145.74,
          "maximum": 508.1468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 508.1468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BRONCHIAL 37FR LFT 125037",
      "code_information": [
        {
          "code": "3572315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 619,
          "minimum": 129.99,
          "maximum": 453.2318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 453.2318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-BLAKEMORE 20 FR      9210",
      "code_information": [
        {
          "code": "3572344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2672,
          "minimum": 561.12,
          "maximum": 1956.4384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1956.4384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 5F 20\\\"     461412",
      "code_information": [
        {
          "code": "3572425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING 6.5F 36\\\"   461438",
      "code_information": [
        {
          "code": "3572430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING NASOGASTRIC 8FR",
      "code_information": [
        {
          "code": "3572485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO FEEDING 18FR 20CC",
      "code_information": [
        {
          "code": "3572530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 237,
          "minimum": 49.77,
          "maximum": 173.5314,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 173.5314,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.5       86215",
      "code_information": [
        {
          "code": "3572860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 7.0       8621",
      "code_information": [
        {
          "code": "3572863",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.0       86212",
      "code_information": [
        {
          "code": "3572865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 6.5       86213",
      "code_information": [
        {
          "code": "3572866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-NASAL RAE 8.0C      86216",
      "code_information": [
        {
          "code": "3572867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
      "code_information": [
        {
          "code": "3573037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
      "code_information": [
        {
          "code": "3573039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 6MM",
      "code_information": [
        {
          "code": "3573355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 517.6654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 8MM",
      "code_information": [
        {
          "code": "3573357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 707,
          "minimum": 148.47,
          "maximum": 517.6654,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 517.6654,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF    SZs  DCTs",
      "code_information": [
        {
          "code": "3573530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 461,
          "minimum": 96.81,
          "maximum": 337.5442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 337.5442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FENESTRATED SZ 4TO10  CFN",
      "code_information": [
        {
          "code": "3573565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JACKSON TRACH #6   518035",
      "code_information": [
        {
          "code": "3573650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2136.5596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFFED 8FR     8LPC",
      "code_information": [
        {
          "code": "3573714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 743,
          "minimum": 156.03,
          "maximum": 544.0246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 544.0246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE,TRAC REINFO 6.0 86548",
      "code_information": [
        {
          "code": "3573730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 234.304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRAC REINFO 7.0     86550",
      "code_information": [
        {
          "code": "3573735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 234.304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEEY PED",
      "code_information": [
        {
          "code": "3573845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 427,
          "minimum": 89.67,
          "maximum": 312.6494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 312.6494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 9.0MM",
      "code_information": [
        {
          "code": "3573903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 583,
          "minimum": 122.43,
          "maximum": 426.8726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 426.8726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU UNCUFF 6.0MM",
      "code_information": [
        {
          "code": "3573905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 520,
          "minimum": 109.2,
          "maximum": 380.744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 380.744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 0.8MM",
      "code_information": [
        {
          "code": "3573906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 501,
          "minimum": 105.21,
          "maximum": 366.8322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 366.8322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FEN 9.0MM",
      "code_information": [
        {
          "code": "3573910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 435,
          "minimum": 91.35,
          "maximum": 318.507,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 318.507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF BLU 10.0MM",
      "code_information": [
        {
          "code": "3573911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH BLU CUFF 6.0MM",
      "code_information": [
        {
          "code": "3573914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 6.0MM",
      "code_information": [
        {
          "code": "3573915",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1400,
          "minimum": 294,
          "maximum": 1025.08,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1025.08,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE 8.0MM",
      "code_information": [
        {
          "code": "3573916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 823.725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH CUFF 7.0MM",
      "code_information": [
        {
          "code": "3573920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 302.3986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED 60A160",
      "code_information": [
        {
          "code": "3573926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 672,
          "minimum": 141.12,
          "maximum": 492.0384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 492.0384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FEN UNCUFF 7MM",
      "code_information": [
        {
          "code": "3573937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH FIXED FLANGE XL 7",
      "code_information": [
        {
          "code": "3573950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 823.725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNDERPAD-CGLIDE XL 40X80 PK",
      "code_information": [
        {
          "code": "3574527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-D&C COLLECTION 23116",
      "code_information": [
        {
          "code": "3574563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 125,
          "minimum": 26.25,
          "maximum": 91.525,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACUUM-MITY-ONE MYSTIC   10058",
      "code_information": [
        {
          "code": "3574642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 661,
          "minimum": 138.81,
          "maximum": 483.9842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 483.9842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-KEITH ANTI-REFLUX",
      "code_information": [
        {
          "code": "3574651",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING TRACH    PMV007",
      "code_information": [
        {
          "code": "3574654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 879,
          "minimum": 184.59,
          "maximum": 643.6038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 643.6038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAX-BONE                  W31G",
      "code_information": [
        {
          "code": "3575105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 84,
          "minimum": 17.64,
          "maximum": 61.5048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 61.5048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WEDGE-CGLIDE FOAM W/COVER XLPK",
      "code_information": [
        {
          "code": "3575115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 414,
          "minimum": 86.94,
          "maximum": 303.1308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 303.1308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MEDTRONIC ATRIAL    6492F",
      "code_information": [
        {
          "code": "3575572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 324,
          "minimum": 68.04,
          "maximum": 237.2328,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.2328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK L/XL",
      "code_information": [
        {
          "code": "3575890",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-THROMBIDISC TOPICAL HEMO",
      "code_information": [
        {
          "code": "3575891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 188.9076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD S/M",
      "code_information": [
        {
          "code": "3575892",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 303.863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER COLD L/XL",
      "code_information": [
        {
          "code": "3575893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 518,
          "minimum": 108.78,
          "maximum": 379.2796,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 379.2796,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-LEG POSITIONER 111618",
      "code_information": [
        {
          "code": "3575894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE COLD PACK S/M",
      "code_information": [
        {
          "code": "3575895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRISTLET-PORTHOLE 6600021150",
      "code_information": [
        {
          "code": "3576870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 55,
          "minimum": 11.55,
          "maximum": 40.271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 40.271,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH 442-2",
      "code_information": [
        {
          "code": "3576880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EXUDE HYDRO 6X6",
      "code_information": [
        {
          "code": "3580000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.1828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-OPTICELL AG+4X5",
      "code_information": [
        {
          "code": "3580001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 137,
          "minimum": 28.77,
          "maximum": 100.3114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 100.3114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 16FR",
      "code_information": [
        {
          "code": "3580005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST RT XS 8",
      "code_information": [
        {
          "code": "3580008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 151,
          "minimum": 31.71,
          "maximum": 110.5622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 110.5622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-WRIST LT XS 8",
      "code_information": [
        {
          "code": "3580009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DETECTOR-CO2 EASY CAP II",
      "code_information": [
        {
          "code": "3580015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 171,
          "minimum": 35.91,
          "maximum": 125.2062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.2062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY ERASE CAUTI 14FR",
      "code_information": [
        {
          "code": "3580016",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 188,
          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.6536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-NASAL L/R STANDARD",
      "code_information": [
        {
          "code": "3580017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 262,
          "minimum": 55.02,
          "maximum": 191.8364,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 191.8364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-ADLT MED CLOSED",
      "code_information": [
        {
          "code": "3580023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 93.7216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,OVAL 5.5X13CM AR-8550COE",
      "code_information": [
        {
          "code": "3580025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 454,
          "minimum": 95.34,
          "maximum": 332.4188,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 332.4188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-DRAIN FUHRMAN PLEUR/PNEUMO",
      "code_information": [
        {
          "code": "3590000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1467,
          "minimum": 308.07,
          "maximum": 1074.1374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1074.1374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTROSTOMY 18FR   100-18",
      "code_information": [
        {
          "code": "3590008",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSAL 10FR  15642-001",
      "code_information": [
        {
          "code": "3590100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REPAIR ASH CATH      RPK01",
      "code_information": [
        {
          "code": "3590134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 693,
          "minimum": 145.53,
          "maximum": 507.4146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 507.4146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBE TRACH UNCUFF 9.0MM",
      "code_information": [
        {
          "code": "3590140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 264.3242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-LMH LMH-1001",
      "code_information": [
        {
          "code": "3598009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1965.957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM 03.130.302",
      "code_information": [
        {
          "code": "3598013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-BLUE RHINO G2",
      "code_information": [
        {
          "code": "3598017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2088.9666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-STERLING 3.0X60X150",
      "code_information": [
        {
          "code": "3598023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1841,
          "minimum": 386.61,
          "maximum": 1347.9802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1347.9802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ORGANIZER-7 DAY PILL 70069L",
      "code_information": [
        {
          "code": "3598024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-I-KNIFE II 8065921502",
      "code_information": [
        {
          "code": "3598025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.9724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARDS-NEONATAL NOISE NON-MAG",
      "code_information": [
        {
          "code": "3598028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 215,
          "minimum": 45.15,
          "maximum": 157.423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 157.423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE RCM-14815",
      "code_information": [
        {
          "code": "3598048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 839,
          "minimum": 176.19,
          "maximum": 614.3158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 614.3158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPEN KNEE ABS-2001-OT",
      "code_information": [
        {
          "code": "3598069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3510.899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE GEL",
      "code_information": [
        {
          "code": "3598076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 183.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-REPLACEMENT GEL",
      "code_information": [
        {
          "code": "3598077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.1828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-SHOULDER GEL",
      "code_information": [
        {
          "code": "3598078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 183.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-SAMPLE EXTENSION 1841-25",
      "code_information": [
        {
          "code": "3598081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 174,
          "minimum": 36.54,
          "maximum": 127.4028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 127.4028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-8MM ENT TUBE NVM5 2010480",
      "code_information": [
        {
          "code": "3598086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1676.0058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-MEGADYNE 10FT SMOKE",
      "code_information": [
        {
          "code": "3598109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 233,
          "minimum": 48.93,
          "maximum": 170.6026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 170.6026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MEGADYNE F/SMOKE",
      "code_information": [
        {
          "code": "3598110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 100,
          "minimum": 21,
          "maximum": 73.22,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 73.22,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-ZIP PEN F/SMOKE EVAC",
      "code_information": [
        {
          "code": "3598111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 354,
          "minimum": 74.34,
          "maximum": 259.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 259.1988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER SO SPECTRUM SU",
      "code_information": [
        {
          "code": "3598112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 409.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MILLER S1 SPECTRUM SU",
      "code_information": [
        {
          "code": "3598113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 409.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 1603G",
      "code_information": [
        {
          "code": "3598114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 1661G",
      "code_information": [
        {
          "code": "3598115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.1828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-FLUID MINIVAC MGVSFT10",
      "code_information": [
        {
          "code": "3598117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHTMAT-ULTRATHIN UA2550",
      "code_information": [
        {
          "code": "3598118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 818,
          "minimum": 171.78,
          "maximum": 598.9396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 598.9396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MEGADYN SPECULUM 23951",
      "code_information": [
        {
          "code": "3598134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-221C-0427",
      "code_information": [
        {
          "code": "3598154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 582.8312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLIDE-OCULAR KDB GLIDE",
      "code_information": [
        {
          "code": "3598156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROVU DISP PHB-03",
      "code_information": [
        {
          "code": "3598158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11119,
          "minimum": 2334.99,
          "maximum": 8141.3318,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8141.3318,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BLUGRIGGS PERC DILATION",
      "code_information": [
        {
          "code": "3598159",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2213,
          "minimum": 464.73,
          "maximum": 1620.3586,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1620.3586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5X10 AR-8610TDC-01C",
      "code_information": [
        {
          "code": "3598172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1719.9378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-EGG 4.0MM 5820-015-040",
      "code_information": [
        {
          "code": "3598178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 2.0 6007-1200",
      "code_information": [
        {
          "code": "3598184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 971,
          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 710.9662,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY SZ 8 8DCFS",
      "code_information": [
        {
          "code": "3598187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TUBT 7MM EMG ET 2010470",
      "code_information": [
        {
          "code": "3598201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2289,
          "minimum": 480.69,
          "maximum": 1676.0058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1676.0058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LAPIPLASTY 40X11 SM-4011",
      "code_information": [
        {
          "code": "3598213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-MULTIPURPOSE TUBING",
      "code_information": [
        {
          "code": "3598219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 143.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-REINFUSION SB1E",
      "code_information": [
        {
          "code": "3598227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 311,
          "minimum": 65.31,
          "maximum": 227.7142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.7142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 3.2 HAMMER 702632",
      "code_information": [
        {
          "code": "3598233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4242,
          "minimum": 890.82,
          "maximum": 3105.9924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3105.9924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FIBERTAK DS AR-8991DS",
      "code_information": [
        {
          "code": "3598238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1938,
          "minimum": 406.98,
          "maximum": 1419.0036,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1419.0036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 PLUS VCP317H",
      "code_information": [
        {
          "code": "3598242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10,
          "minimum": 2.1,
          "maximum": 7.322,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7.322,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.7MM CSS-072-37-SQ",
      "code_information": [
        {
          "code": "3598257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1062.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-Z-FLO FLUID",
      "code_information": [
        {
          "code": "3598273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 441,
          "minimum": 92.61,
          "maximum": 322.9002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 322.9002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-25 G00896",
      "code_information": [
        {
          "code": "3598279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 193,
          "minimum": 40.53,
          "maximum": 141.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 141.3146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-HIGH TORQUE 70-2001",
      "code_information": [
        {
          "code": "3598282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1378,
          "minimum": 289.38,
          "maximum": 1008.9716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1008.9716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP523H",
      "code_information": [
        {
          "code": "3598283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.3252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.3MM AR-7535",
      "code_information": [
        {
          "code": "3598289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 546.9534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYNGECTOMY SZ10 6132",
      "code_information": [
        {
          "code": "3598291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2343,
          "minimum": 492.03,
          "maximum": 1715.5446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1715.5446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUNCTURE 17FR/10MM 8141US",
      "code_information": [
        {
          "code": "3598296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2695,
          "minimum": 565.95,
          "maximum": 1973.279,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1973.279,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-E-Z CLEAN 0016AM",
      "code_information": [
        {
          "code": "3598301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 83,
          "minimum": 17.43,
          "maximum": 60.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.7726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 22GX.75\\\"",
      "code_information": [
        {
          "code": "3598320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL 80M 04.038.380S",
      "code_information": [
        {
          "code": "3598333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4478,
          "minimum": 940.38,
          "maximum": 3278.7916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3278.7916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-URINE METER 350ML 153204",
      "code_information": [
        {
          "code": "3598338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 SURGILON 8886195151",
      "code_information": [
        {
          "code": "3598362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.1998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 SURGILON 8886195141",
      "code_information": [
        {
          "code": "3598363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.1828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-SUB LIPO 3-TT-FILTRON",
      "code_information": [
        {
          "code": "3598384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2403,
          "minimum": 504.63,
          "maximum": 1759.4766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1759.4766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHEST-DRAIN 4050-100N",
      "code_information": [
        {
          "code": "3598393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.2594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEO TEE 1050810",
      "code_information": [
        {
          "code": "3598397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 210.8736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DECANNULATION SZ:8",
      "code_information": [
        {
          "code": "3598398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 343,
          "minimum": 72.03,
          "maximum": 251.1446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.1446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORAPREP 10.5 CLR",
      "code_information": [
        {
          "code": "3598403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY L-WIRE 20115",
      "code_information": [
        {
          "code": "3598404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 362,
          "minimum": 76.02,
          "maximum": 265.0564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.0564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-LIGATING SURGITIE SGL-1",
      "code_information": [
        {
          "code": "3598405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 621,
          "minimum": 130.41,
          "maximum": 454.6962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 454.6962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 11 96\\\" Z880G",
      "code_information": [
        {
          "code": "3598407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-POWER 45MM FLEX PSEE45",
      "code_information": [
        {
          "code": "3598408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2062,
          "minimum": 433.02,
          "maximum": 1509.7964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1509.7964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 32FR 056132",
      "code_information": [
        {
          "code": "3598409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SOFSIK 2-0 18\\\" GS63M",
      "code_information": [
        {
          "code": "3598410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 228,
          "minimum": 47.88,
          "maximum": 166.9416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 166.9416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOSOF 5-0 SN-661",
      "code_information": [
        {
          "code": "3598412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 1 G48",
      "code_information": [
        {
          "code": "3598413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 147,
          "minimum": 30.87,
          "maximum": 107.6334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 107.6334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 0 3844G",
      "code_information": [
        {
          "code": "3598415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 6-0 714G",
      "code_information": [
        {
          "code": "3598417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BLOOD WARMING RAPID 24355",
      "code_information": [
        {
          "code": "3598418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 323.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYSTOLOGY 2.3MMX240CM",
      "code_information": [
        {
          "code": "3598419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 242,
          "minimum": 50.82,
          "maximum": 177.1924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 177.1924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CAUTERY LONG 2.4MM E1450-6",
      "code_information": [
        {
          "code": "3598420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 Y527H",
      "code_information": [
        {
          "code": "3598424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-GRAVITY SPIKE FLUID MGMT",
      "code_information": [
        {
          "code": "3598425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEM SILVER 6.5X7",
      "code_information": [
        {
          "code": "3598426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 229,
          "minimum": 48.09,
          "maximum": 167.6738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 167.6738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 20FR 5CC",
      "code_information": [
        {
          "code": "3598427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-J-TIP .035X145CM",
      "code_information": [
        {
          "code": "3598428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 241.626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3-WAY 30CC 16FR",
      "code_information": [
        {
          "code": "3598429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2 490T",
      "code_information": [
        {
          "code": "3598434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII BLADED CTB33",
      "code_information": [
        {
          "code": "3598436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM BLADELESS CTR03",
      "code_information": [
        {
          "code": "3598437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-WOUND 10FR DYNJWE1321A",
      "code_information": [
        {
          "code": "3598439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 109,
          "minimum": 22.89,
          "maximum": 79.8098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.8098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ULNAR NERVE 79-91100",
      "code_information": [
        {
          "code": "3598441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 65,
          "minimum": 13.65,
          "maximum": 47.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POWDER-HEMOSTAT AVITENE 1 GRAM",
      "code_information": [
        {
          "code": "3598442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1703,
          "minimum": 357.63,
          "maximum": 1246.9366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1246.9366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RADIAL ARTERY 20GX1.75\\\"",
      "code_information": [
        {
          "code": "3598444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 265,
          "minimum": 55.65,
          "maximum": 194.033,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 194.033,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL RHINO ROCKET LRG",
      "code_information": [
        {
          "code": "3598446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-FOREIGN BODY 60613",
      "code_information": [
        {
          "code": "3598447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 663,
          "minimum": 139.23,
          "maximum": 485.4486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 485.4486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ROBINSON 24FR 056124",
      "code_information": [
        {
          "code": "3598448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-HYDROFERA 6X6 HB6614",
      "code_information": [
        {
          "code": "3598449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 218,
          "minimum": 45.78,
          "maximum": 159.6196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 159.6196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SMALL WIDE",
      "code_information": [
        {
          "code": "3598450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 160.3518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARYNGECTOMY SZ6 6LGT",
      "code_information": [
        {
          "code": "3598451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 457,
          "minimum": 95.97,
          "maximum": 334.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 334.6154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5X285MM 703586",
      "code_information": [
        {
          "code": "3598458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 414.4252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 414.4252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 18FR",
      "code_information": [
        {
          "code": "3598463",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 717.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1X285MM 703585",
      "code_information": [
        {
          "code": "3598464",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1125,
          "minimum": 236.25,
          "maximum": 823.725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 823.725,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATFORM-GELPOINT PATH CNB11",
      "code_information": [
        {
          "code": "3598471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3614.1392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-VINYL CONNECTING G02791",
      "code_information": [
        {
          "code": "3598473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 169.1382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRUIT, CROSS VENT 80011",
      "code_information": [
        {
          "code": "3598474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 323,
          "minimum": 67.83,
          "maximum": 236.5006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 236.5006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR, NEO W/MASK",
      "code_information": [
        {
          "code": "3598475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 342,
          "minimum": 71.82,
          "maximum": 250.4124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 250.4124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TEMPLATE-RIB PLATE 12H 76-9102",
      "code_information": [
        {
          "code": "3598478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 779,
          "minimum": 163.59,
          "maximum": 570.3838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 570.3838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC #1 48G",
      "code_information": [
        {
          "code": "3598479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 93.7216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-BIPOLAR STEM 222-496100",
      "code_information": [
        {
          "code": "3598480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5912,
          "minimum": 1241.52,
          "maximum": 4328.7664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4328.7664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRIP-PLATINUM MS04R-IP10X-0JH",
      "code_information": [
        {
          "code": "3598481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4118,
          "minimum": 864.78,
          "maximum": 3015.1996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3015.1996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-ENDOCAPSULE 10 MAJ2027",
      "code_information": [
        {
          "code": "3598483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3003,
          "minimum": 630.63,
          "maximum": 2198.7966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2198.7966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-10G/7.75\\\" 0306-810-000",
      "code_information": [
        {
          "code": "3598484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 724,
          "minimum": 152.04,
          "maximum": 530.1128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 530.1128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77420",
      "code_information": [
        {
          "code": "3598485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 584,
          "minimum": 122.64,
          "maximum": 427.6048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 427.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/SUPPORT #6",
      "code_information": [
        {
          "code": "3598487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 784,
          "minimum": 164.64,
          "maximum": 574.0448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 574.0448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST 4050-100N",
      "code_information": [
        {
          "code": "3598488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 516.9332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-GONIOTOMY TRABEX 600042",
      "code_information": [
        {
          "code": "3598489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3014,
          "minimum": 632.94,
          "maximum": 2206.8508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2206.8508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW NSLX137C",
      "code_information": [
        {
          "code": "3598494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2637,
          "minimum": 553.77,
          "maximum": 1930.8114,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1930.8114,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENSEAL-CVD JAW 25CM NSLX125C",
      "code_information": [
        {
          "code": "3598495",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2676,
          "minimum": 561.96,
          "maximum": 1959.3672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1959.3672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-JADA POSTPARTUM",
      "code_information": [
        {
          "code": "3598497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5844,
          "minimum": 1227.24,
          "maximum": 4278.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4278.9768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA G PROCEDURAL PUG",
      "code_information": [
        {
          "code": "3598498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9014,
          "minimum": 1892.94,
          "maximum": 6600.0508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 6600.0508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-4MM/SHORT 1149.8052",
      "code_information": [
        {
          "code": "3598502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1867.8422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN",
      "code_information": [
        {
          "code": "3598508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN",
      "code_information": [
        {
          "code": "3598509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1055,
          "minimum": 221.55,
          "maximum": 772.471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 772.471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94975",
      "code_information": [
        {
          "code": "3598515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1030,
          "minimum": 216.3,
          "maximum": 754.166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 754.166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LARYN W/EL SZ10 6136",
      "code_information": [
        {
          "code": "3598520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4004,
          "minimum": 840.84,
          "maximum": 2931.7288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2931.7288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE-1.4X100/LG AGK10100",
      "code_information": [
        {
          "code": "3598521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 442,
          "minimum": 92.82,
          "maximum": 323.6324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 323.6324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .9X120MM 45302001",
      "code_information": [
        {
          "code": "3598524",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 288.4868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "UNIT-TI-KNOT QUICK LOAD 030510",
      "code_information": [
        {
          "code": "3598527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-PICO 14 WOUND 15X30CM",
      "code_information": [
        {
          "code": "3598530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1724,
          "minimum": 362.04,
          "maximum": 1262.3128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1262.3128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1590,
          "minimum": 333.9,
          "maximum": 1164.198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1164.198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY STANDARD 7607",
      "code_information": [
        {
          "code": "3598534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1347,
          "minimum": 282.87,
          "maximum": 986.2734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 986.2734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND XTRASORB 6X9",
      "code_information": [
        {
          "code": "3598535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-FLEX INTUBATION 5.3X65",
      "code_information": [
        {
          "code": "3598536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1828,
          "minimum": 383.88,
          "maximum": 1338.4616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1338.4616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOLDER-ET TUBE THOMAS SELECT",
      "code_information": [
        {
          "code": "3598538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY",
      "code_information": [
        {
          "code": "3598539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1496,
          "minimum": 314.16,
          "maximum": 1095.3712,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1095.3712,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL LK/MD 3.1X328 705077",
      "code_information": [
        {
          "code": "3598547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1526,
          "minimum": 320.46,
          "maximum": 1117.3372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1117.3372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-E-CATH PLUS 251285-41E",
      "code_information": [
        {
          "code": "3598551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEPS-OVAL CUP BIOPSY SINGLE",
      "code_information": [
        {
          "code": "3598561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 428.337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEATED W/GAS FILTER",
      "code_information": [
        {
          "code": "3598562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 652,
          "minimum": 136.92,
          "maximum": 477.3944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 477.3944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-10X360/RT/130* 3430-0360S",
      "code_information": [
        {
          "code": "3598565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6277,
          "minimum": 1318.17,
          "maximum": 4596.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4596.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RETRIEVAL 5MM CD003",
      "code_information": [
        {
          "code": "3598587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.1X65MM 03.130.201",
      "code_information": [
        {
          "code": "3598592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1114,
          "minimum": 233.94,
          "maximum": 815.6708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 815.6708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-AIRSEAL CANN 8MM IAS8-DV",
      "code_information": [
        {
          "code": "3598593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 822.2606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTERD FURCATED ASM-EVAC",
      "code_information": [
        {
          "code": "3598594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1123,
          "minimum": 235.83,
          "maximum": 822.2606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 822.2606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-HEMOSTASIS + MAP152",
      "code_information": [
        {
          "code": "3598601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRIVE T6 VARIAX2 705132",
      "code_information": [
        {
          "code": "3598602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2210,
          "minimum": 464.1,
          "maximum": 1618.162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1618.162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SCREW T7 AO 45-27015",
      "code_information": [
        {
          "code": "3598609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1540,
          "minimum": 323.4,
          "maximum": 1127.588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1127.588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PROXIMATE PROCEDURE PPH03",
      "code_information": [
        {
          "code": "3598617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2668,
          "minimum": 560.28,
          "maximum": 1953.5096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1953.5096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X7MM 60-16007",
      "code_information": [
        {
          "code": "3598624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1349,
          "minimum": 283.29,
          "maximum": 987.7378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 987.7378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-1.9X115/35MM 92-19135",
      "code_information": [
        {
          "code": "3598625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2047,
          "minimum": 429.87,
          "maximum": 1498.8134,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1498.8134,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 102.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ENDO BSC CEK-1021-20",
      "code_information": [
        {
          "code": "3598631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 263,
          "minimum": 55.23,
          "maximum": 192.5686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 192.5686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-EDIPURAL 17GX3.5 BUPIV",
      "code_information": [
        {
          "code": "3598647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 362,
          "minimum": 76.02,
          "maximum": 265.0564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.0564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 0.3MM DWD055",
      "code_information": [
        {
          "code": "3598653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1389,
          "minimum": 291.69,
          "maximum": 1017.0258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1017.0258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #2",
      "code_information": [
        {
          "code": "3598662",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 606.2616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDICLE ACCESS 624.027S",
      "code_information": [
        {
          "code": "3598668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3304.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COVER-DISTAL DUODENOVIDEOSCOPE",
      "code_information": [
        {
          "code": "3598674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR",
      "code_information": [
        {
          "code": "3598678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 974,
          "minimum": 204.54,
          "maximum": 713.1628,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 713.1628,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 24FR 77424",
      "code_information": [
        {
          "code": "3598679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 486,
          "minimum": 102.06,
          "maximum": 355.8492,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 355.8492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X13MM AR-300-B001",
      "code_information": [
        {
          "code": "3598688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2343,
          "minimum": 492.03,
          "maximum": 1715.5446,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1715.5446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X19.5MM AR-300-B201",
      "code_information": [
        {
          "code": "3598689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2396,
          "minimum": 503.16,
          "maximum": 1754.3512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1754.3512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8710H",
      "code_information": [
        {
          "code": "3598695",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 PROLENE EPH8725H",
      "code_information": [
        {
          "code": "3598696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 385,
          "minimum": 80.85,
          "maximum": 281.897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 281.897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8806H",
      "code_information": [
        {
          "code": "3598697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 234.304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8718H",
      "code_information": [
        {
          "code": "3598698",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 258,
          "minimum": 54.18,
          "maximum": 188.9076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 188.9076,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-6-0 PROLENE EP8714H",
      "code_information": [
        {
          "code": "3598699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 215,
          "minimum": 45.15,
          "maximum": 157.423,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 157.423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W SPPRT MXPRSK05",
      "code_information": [
        {
          "code": "3598700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 606.2616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-BENSTON 260CM/.035\\\"",
      "code_information": [
        {
          "code": "3598702",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 212,
          "minimum": 44.52,
          "maximum": 155.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 155.2264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PESSARY-RING W/ SUPPORT #3",
      "code_information": [
        {
          "code": "3598704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 828,
          "minimum": 173.88,
          "maximum": 606.2616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 606.2616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-LT 130°/10X420 3530-0420S",
      "code_information": [
        {
          "code": "3598705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6277,
          "minimum": 1318.17,
          "maximum": 4596.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4596.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-XI 45MM 480445",
      "code_information": [
        {
          "code": "3598714",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3242,
          "minimum": 680.82,
          "maximum": 2373.7924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2373.7924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALLOON-MUSTANG 7.0X20X135CM",
      "code_information": [
        {
          "code": "3598729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 997.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT,ACTIVE ANKLE HEEL-LOCK",
      "code_information": [
        {
          "code": "3598758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 464,
          "minimum": 97.44,
          "maximum": 339.7408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 339.7408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Suture-7-0 Prolene Blue 8704H",
      "code_information": [
        {
          "code": "3598759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 271,
          "minimum": 56.91,
          "maximum": 198.4262,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.4262,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR,SURGICEL 3123SPEA",
      "code_information": [
        {
          "code": "3598761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 322,
          "minimum": 67.62,
          "maximum": 235.7684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.7684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP ESREC",
      "code_information": [
        {
          "code": "3598782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 3.0X2.1 45-30005",
      "code_information": [
        {
          "code": "3598799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1849,
          "minimum": 388.29,
          "maximum": 1353.8378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1353.8378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-TRANSPAC 425840405",
      "code_information": [
        {
          "code": "3598801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 126.6706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5MM AR-8737-37",
      "code_information": [
        {
          "code": "3598812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE,.045\\\" THD AR-8737-05",
      "code_information": [
        {
          "code": "3598815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.1956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO 2.0MM DC6106",
      "code_information": [
        {
          "code": "3598843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1277.689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 2.5X150MM 58862515",
      "code_information": [
        {
          "code": "3598844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.1X150MM DSDS1011",
      "code_information": [
        {
          "code": "3598845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.5MM DSDS0025",
      "code_information": [
        {
          "code": "3598846",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1395.5732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.0MM DSDS0030",
      "code_information": [
        {
          "code": "3598853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1395.5732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR SHEEHY 510-131C",
      "code_information": [
        {
          "code": "3598870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 205,
          "minimum": 43.05,
          "maximum": 150.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.101,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR PAPERELLA 510-043C",
      "code_information": [
        {
          "code": "3598871",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 161.084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F X-FIT 60-80323",
      "code_information": [
        {
          "code": "3598874",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1062.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F 1.7MM 60-80317",
      "code_information": [
        {
          "code": "3598875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1062.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EAR-SPEEDIWICK 15MM OT-5201-50",
      "code_information": [
        {
          "code": "3598882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-APR 15CM APYX-15-TP",
      "code_information": [
        {
          "code": "3598955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3007,
          "minimum": 631.47,
          "maximum": 2201.7254,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2201.7254,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERIOTOMY",
      "code_information": [
        {
          "code": "3598957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 646.5326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABD 12\\\"/46-62\\\" 1143PP",
      "code_information": [
        {
          "code": "3598975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 115,
          "minimum": 24.15,
          "maximum": 84.203,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 6.0 BIPOLAR",
      "code_information": [
        {
          "code": "3598997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2604,
          "minimum": 546.84,
          "maximum": 1906.6488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1906.6488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COAGULATOR-SUCTION 004025",
      "code_information": [
        {
          "code": "3599029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-WIGGLE OPTIFLOW JR 2 M",
      "code_information": [
        {
          "code": "3599030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-HAND HANZ RT LG",
      "code_information": [
        {
          "code": "3599041",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 494,
          "minimum": 103.74,
          "maximum": 361.7068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 361.7068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.65MM MD 45303065",
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        {
          "code": "3599049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2.55MM MD 45303055",
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        {
          "code": "3599050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 8305H",
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        {
          "code": "3599073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-S-CURVE URETH DIL G32789",
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        {
          "code": "3599074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 427.56,
          "maximum": 1490.7592,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.5x57MM 03.130.211",
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        {
          "code": "3599095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
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        {
          "code": "3599096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002352",
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        {
          "code": "3599098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 475.02,
          "maximum": 1656.2364,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3 LONG NAIL 415S002351",
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        {
          "code": "3599099",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2262,
          "minimum": 475.02,
          "maximum": 1656.2364,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1656.2364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-BEADED 3MM 4150004030",
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        {
          "code": "3599100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LONG ENCOMPASS JAW OLH",
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        {
          "code": "3599110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 4776.24,
          "maximum": 16653.1568,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-MAGNETIC PATH GPM100",
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        {
          "code": "3599114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1025.01,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-270-330C ALLOX-FH12SE",
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        {
          "code": "3599115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1359.75,
          "maximum": 4740.995,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4740.995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2.3MM CSS-040-23",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 69.09,
          "maximum": 240.8938,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KWIRE-NAIL 3MM 4150004025",
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        {
          "code": "3599135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHIONS-FULL VIP1137430",
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        {
          "code": "3599140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-FILL VIP1137431",
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          "code": "3599141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 59.64,
          "maximum": 207.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISH-INCONTINENCE SUPPORT #4",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 182.7,
          "maximum": 637.014,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-HINGED KNEE LG 11-0672-4",
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        {
          "code": "3599145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 638.4784,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 638.4784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GAUGE-PROCESSOR DEPTH Z179994",
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        {
          "code": "3599155",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 508.83,
          "maximum": 1774.1206,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X230/200MM 315.93",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 383.46,
          "maximum": 1336.9972,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1336.9972,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TENSIONER-CERCLAGE AR-7820",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 1486.366,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CERCLAGE STR/LG AR-7822",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-INS MID/HINDFOOT FFSP1530",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM AR-4160-40",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SET RENOVARP GIS-30",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.5/135X45 03.133.102",
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        {
          "code": "3599237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1522,
          "minimum": 319.62,
          "maximum": 1114.4084,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-100.783+/3H 954-0035",
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        {
          "code": "3599249",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1448,
          "minimum": 304.08,
          "maximum": 1060.2256,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1060.2256,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PARACENTESIS GIS-31",
      "code_information": [
        {
          "code": "3599291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 940,
          "minimum": 197.4,
          "maximum": 688.268,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 688.268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 2 1/2\\\"",
      "code_information": [
        {
          "code": "3599298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-HEEL MEDIAL/LATERAL 3\\\"",
      "code_information": [
        {
          "code": "3599299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-PLANTAR KERATOSIS WOMENS",
      "code_information": [
        {
          "code": "3599300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" SMALL",
      "code_information": [
        {
          "code": "3599306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" MEDIUM",
      "code_information": [
        {
          "code": "3599307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIFT-HEEL 1/8\\\" LARGE",
      "code_information": [
        {
          "code": "3599308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.1828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE DOUBLE",
      "code_information": [
        {
          "code": "3599309",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE SINGLE",
      "code_information": [
        {
          "code": "3599310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE LEFT",
      "code_information": [
        {
          "code": "3599311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-BUDIN TOE THREE RIGHT",
      "code_information": [
        {
          "code": "3599312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 25GX5”",
      "code_information": [
        {
          "code": "3599313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 251,
          "minimum": 52.71,
          "maximum": 183.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 183.7822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-DERMABOND PRINEO ADHESIVE",
      "code_information": [
        {
          "code": "3599314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1037,
          "minimum": 217.77,
          "maximum": 759.2914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 759.2914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OXYGENATOR-PERFUSION 050715",
      "code_information": [
        {
          "code": "3599315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1812,
          "minimum": 380.52,
          "maximum": 1326.7464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1326.7464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-Y TYPE PERFUSION 10004",
      "code_information": [
        {
          "code": "3599362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.1658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 19G X 1.5\\\"CT",
      "code_information": [
        {
          "code": "3599369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.0606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CUSTOM TUBING 8H23R12",
      "code_information": [
        {
          "code": "3599370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2383,
          "minimum": 500.43,
          "maximum": 1744.8326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1744.8326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.7/125MM 03.133.105",
      "code_information": [
        {
          "code": "3599378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1325,
          "minimum": 278.25,
          "maximum": 970.165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 970.165,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-PIECE-OXYGEN MONITOR",
      "code_information": [
        {
          "code": "3599381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AGENT-LIFTING 5ML GIS-55",
      "code_information": [
        {
          "code": "3599412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-FINGER XL A8685",
      "code_information": [
        {
          "code": "3599413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 220,
          "minimum": 46.2,
          "maximum": 161.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 161.084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY 040-300",
      "code_information": [
        {
          "code": "3599414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RET 5MM/155CM FB-231D.A",
      "code_information": [
        {
          "code": "3599417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-QC 2.8/135X45 03.133.106",
      "code_information": [
        {
          "code": "3599424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1497,
          "minimum": 314.37,
          "maximum": 1096.1034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1096.1034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DUAL N8 PROCESSOR DUALN8",
      "code_information": [
        {
          "code": "3599512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62546,
          "minimum": 13134.66,
          "maximum": 45796.1812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45796.1812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0 EPM8703",
      "code_information": [
        {
          "code": "3599513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 901,
          "minimum": 189.21,
          "maximum": 659.7122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 659.7122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X150MM 03.333.002",
      "code_information": [
        {
          "code": "3599527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 944,
          "minimum": 198.24,
          "maximum": 691.1968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 691.1968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOYSTICK-RED 5MM 03.211.454",
      "code_information": [
        {
          "code": "3599531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2911,
          "minimum": 611.31,
          "maximum": 2131.4342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2131.4342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IABC 40CC 7FR IMU7F-40",
      "code_information": [
        {
          "code": "3599539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5359,
          "minimum": 1125.39,
          "maximum": 3923.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3923.8598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-SD 2MM T6 313.843.V",
      "code_information": [
        {
          "code": "3599548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1853,
          "minimum": 389.13,
          "maximum": 1356.7666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1356.7666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIX 1.1MM DC4212",
      "code_information": [
        {
          "code": "3599593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1180,
          "minimum": 247.8,
          "maximum": 863.996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 863.996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 70MM",
      "code_information": [
        {
          "code": "3599601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.1722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-NASAL TUBING BUBBLE 100MM",
      "code_information": [
        {
          "code": "3599602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 201,
          "minimum": 42.21,
          "maximum": 147.1722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.1722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE SMALL",
      "code_information": [
        {
          "code": "3599607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.9384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE MEDIUM",
      "code_information": [
        {
          "code": "3599608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.9384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE LARGE",
      "code_information": [
        {
          "code": "3599609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.9384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-CPAP BUBBLE X-LARGE",
      "code_information": [
        {
          "code": "3599610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 172,
          "minimum": 36.12,
          "maximum": 125.9384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.9384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 3520",
      "code_information": [
        {
          "code": "3599611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4030",
      "code_information": [
        {
          "code": "3599612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 4540",
      "code_information": [
        {
          "code": "3599613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5040",
      "code_information": [
        {
          "code": "3599614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PRONG-CPAP BUBBLE NASAL 5550",
      "code_information": [
        {
          "code": "3599615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 139,
          "minimum": 29.19,
          "maximum": 101.7758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 35-40CM",
      "code_information": [
        {
          "code": "3599617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 293,
          "minimum": 61.53,
          "maximum": 214.5346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 214.5346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPAP-HEADGEAR BUBBLE 40-45CM",
      "code_information": [
        {
          "code": "3599618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 293,
          "minimum": 61.53,
          "maximum": 214.5346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 214.5346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE CVD AC-20055390",
      "code_information": [
        {
          "code": "3599638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1368,
          "minimum": 287.28,
          "maximum": 1001.6496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1001.6496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-OTOLASE STRAIGHT",
      "code_information": [
        {
          "code": "3599639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1369,
          "minimum": 287.49,
          "maximum": 1002.3818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1002.3818,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .315\\\" NAR 200138107S",
      "code_information": [
        {
          "code": "3599664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW .50\\\" WIDE 200138108S",
      "code_information": [
        {
          "code": "3599666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REMOVER-BONE SCREW IB200051",
      "code_information": [
        {
          "code": "3599670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1584,
          "minimum": 332.64,
          "maximum": 1159.8048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1159.8048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDES-PT SPECIFIC PROPINF",
      "code_information": [
        {
          "code": "3599671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7311,
          "minimum": 1535.31,
          "maximum": 5353.1142,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5353.1142,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 2.4MM 200072",
      "code_information": [
        {
          "code": "3599672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 561,
          "minimum": 117.81,
          "maximum": 410.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 410.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CORNER 4.8MM 33600048",
      "code_information": [
        {
          "code": "3599673",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2020,
          "minimum": 424.2,
          "maximum": 1479.044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1479.044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACID-5% ACETIC 9045052",
      "code_information": [
        {
          "code": "3599696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ORAL CARE DUOCARE MDS604DC",
      "code_information": [
        {
          "code": "3599708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.2604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/4X1/4X1/4 6030",
      "code_information": [
        {
          "code": "3599751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.3252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-INTERSEPT 6031",
      "code_information": [
        {
          "code": "3599752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X1/4X1/4 Y 6036",
      "code_information": [
        {
          "code": "3599753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-Y 1/2X3/8X3/8 6040",
      "code_information": [
        {
          "code": "3599754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 66,
          "minimum": 13.86,
          "maximum": 48.3252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.3252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PERFUSE 1/4\\\" 10007",
      "code_information": [
        {
          "code": "3599756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/M P01-900-1703",
      "code_information": [
        {
          "code": "3599770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1980.601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH 82-1516",
      "code_information": [
        {
          "code": "3599774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1505,
          "minimum": 316.05,
          "maximum": 1101.961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1101.961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOPRO-VASOVIEW 2 VEIN",
      "code_information": [
        {
          "code": "3599778",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6789,
          "minimum": 1425.69,
          "maximum": 4970.9058,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4970.9058,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENFIT 6.5F 36\\\"",
      "code_information": [
        {
          "code": "3599780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 79,
          "minimum": 16.59,
          "maximum": 57.8438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.8438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-UNIVERSAL PALM MEDIUM",
      "code_information": [
        {
          "code": "3599787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ESPOCAN CSE 17GX4.5\\\"",
      "code_information": [
        {
          "code": "3599788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 231,
          "minimum": 48.51,
          "maximum": 169.1382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 169.1382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPACER IN-LINE 42-RTC24-VP",
      "code_information": [
        {
          "code": "3599789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 98,
          "minimum": 20.58,
          "maximum": 71.7556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.7556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-PRIMARY DUOVENT 1424828",
      "code_information": [
        {
          "code": "3599790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 133,
          "minimum": 27.93,
          "maximum": 97.3826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 97.3826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-PED ANES W/FILTER",
      "code_information": [
        {
          "code": "3599791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 143,
          "minimum": 30.03,
          "maximum": 104.7046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 104.7046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 45MM",
      "code_information": [
        {
          "code": "3599808",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2874,
          "minimum": 603.54,
          "maximum": 2104.3428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2104.3428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 3000 60MM",
      "code_information": [
        {
          "code": "3599809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3133,
          "minimum": 657.93,
          "maximum": 2293.9826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2293.9826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 368,
          "minimum": 77.28,
          "maximum": 269.4496,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 269.4496,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ARTERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 372,
          "minimum": 78.12,
          "maximum": 272.3784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 272.3784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ATERIAL PERFUSION 20F",
      "code_information": [
        {
          "code": "3599820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 255,
          "minimum": 53.55,
          "maximum": 186.711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 186.711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 10CM SHORT",
      "code_information": [
        {
          "code": "3599881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 120,
          "minimum": 25.2,
          "maximum": 87.864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL K 8CM SHORT",
      "code_information": [
        {
          "code": "3599882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-LP 2MMX4CM RBYLP0204",
      "code_information": [
        {
          "code": "3599885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4457,
          "minimum": 935.97,
          "maximum": 3263.4154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3263.4154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-1.1X70 KWIRE 03.130.200",
      "code_information": [
        {
          "code": "3599922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5X7 STD AR-7350TD",
      "code_information": [
        {
          "code": "3599951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 811.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY G 18FR 2.7",
      "code_information": [
        {
          "code": "3599960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 717.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-GRASPING DISP FG-600U",
      "code_information": [
        {
          "code": "3600018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 782,
          "minimum": 164.22,
          "maximum": 572.5804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 572.5804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT 10012",
      "code_information": [
        {
          "code": "3600074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 227,
          "minimum": 47.67,
          "maximum": 166.2094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 166.2094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 9/36 7413",
      "code_information": [
        {
          "code": "3600119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1452,
          "minimum": 304.92,
          "maximum": 1063.1544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1063.1544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-PROVOX XTRAFLOW HME",
      "code_information": [
        {
          "code": "3600120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LARY 10/36",
      "code_information": [
        {
          "code": "3600121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1451,
          "minimum": 304.71,
          "maximum": 1062.4222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1062.4222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-THORA/PARA 6FRTAPS-6F-12PT",
      "code_information": [
        {
          "code": "3600163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 835,
          "minimum": 175.35,
          "maximum": 611.387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 611.387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-GOMCO CIRCUMCISION 1.3CM",
      "code_information": [
        {
          "code": "3600165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 605,
          "minimum": 127.05,
          "maximum": 442.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 442.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNOTOMY 046-367",
      "code_information": [
        {
          "code": "3600166",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-SELF LOCKING 4933-0-802",
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        {
          "code": "3600214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 39.48,
          "maximum": 137.6536,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH14 050179",
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        {
          "code": "3600219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 203.91,
          "maximum": 710.9662,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R501-26",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 241.626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL XS EVF1XSLA",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 53.13,
          "maximum": 185.2466,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL S-M EVF1MSLA",
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        {
          "code": "3600222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 53.13,
          "maximum": 185.2466,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 185.2466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA FULL L EVF1LSLA",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 53.13,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-EVORA NASAL EVO1SMLSL",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 49.98,
          "maximum": 174.2636,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY LTX FRE 8 5 165808",
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        {
          "code": "3600233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 11.76,
          "maximum": 41.0032,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SZ 0 VLOCM2146",
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        {
          "code": "3600255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 81.9,
          "maximum": 285.558,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 BARBED VLOCL0615",
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          "code": "3600256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 122.85,
          "maximum": 428.337,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X285MM 703583",
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        {
          "code": "3600270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT R502-15",
      "code_information": [
        {
          "code": "3600272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 75.18,
          "maximum": 262.1276,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ROOT AR-11114",
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        {
          "code": "3600273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO 125MM AR-3210-0051",
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        {
          "code": "3600300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR,SUCTION 8MM 480299",
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        {
          "code": "3600302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 392.28,
          "maximum": 1367.7496,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-2.3MM INLINE DRILL MOUTH",
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          "code": "3600308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SPIRAL 7000AAO",
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        {
          "code": "3600310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 14.07,
          "maximum": 49.0574,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ONESTEP 5F OSC-5F-12PT/C",
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        {
          "code": "3600311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 98.28,
          "maximum": 342.6696,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NASAL ETOC2 ADT",
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        {
          "code": "3600315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-48MM EZOUT 7812-048-001K",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-50MM EZOUT 7812-050-001K",
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        {
          "code": "3600317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3717.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC/SAG 5.5 2296-023-412",
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        {
          "code": "3600318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FAT TRANS VIALITY-1400",
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        {
          "code": "3600331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2478.497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
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        {
          "code": "3600343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL 3.5/2.5 AR-8943-14",
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        {
          "code": "3600344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 839.58,
          "maximum": 2927.3356,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2927.3356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 MONOTEX T8623",
      "code_information": [
        {
          "code": "3600351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-VISION SUCTION PROBE",
      "code_information": [
        {
          "code": "3600353",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 19G BIOPSY",
      "code_information": [
        {
          "code": "3600355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 21G BIOPSY",
      "code_information": [
        {
          "code": "3600356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FLEXISION 23G BIOPSY",
      "code_information": [
        {
          "code": "3600357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DECLOGGER-FEEDING TUBE 14-16FR",
      "code_information": [
        {
          "code": "3600358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 130.3316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 5X356/126MM 03.008.008",
      "code_information": [
        {
          "code": "3600375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1921,
          "minimum": 403.41,
          "maximum": 1406.5562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1406.5562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROC 2.3X230 P99-194-2323",
      "code_information": [
        {
          "code": "3600390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7MM AO AR-18800-20",
      "code_information": [
        {
          "code": "3600412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 997.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HUMIDIFIER-CPAP HC325S",
      "code_information": [
        {
          "code": "3600428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 105.4368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE M001141006",
      "code_information": [
        {
          "code": "3600430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1293,
          "minimum": 271.53,
          "maximum": 946.7346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 946.7346,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-2-2.7MM 706200",
      "code_information": [
        {
          "code": "3600436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1410,
          "minimum": 296.1,
          "maximum": 1032.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1032.402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-8MM/SD LORD 1088-43-008",
      "code_information": [
        {
          "code": "3600449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2891.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-6MM/SD PARA 108843106",
      "code_information": [
        {
          "code": "3600452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2891.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAFT-REAMER FLX 4150016000",
      "code_information": [
        {
          "code": "3600467",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4998,
          "minimum": 1049.58,
          "maximum": 3659.5356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3659.5356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-9X250 STP 4150002090",
      "code_information": [
        {
          "code": "3600471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1592.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-FETAL C-SECTION",
      "code_information": [
        {
          "code": "3600474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4109.8386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-BAND POLY CFI-733",
      "code_information": [
        {
          "code": "3600493",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.1116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC PUMP 8\\\" AR-6411",
      "code_information": [
        {
          "code": "3600498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 765,
          "minimum": 160.65,
          "maximum": 560.133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 560.133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-RDC OUTFLOW AR-6435",
      "code_information": [
        {
          "code": "3600499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 752,
          "minimum": 157.92,
          "maximum": 550.6144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 550.6144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY M00516071",
      "code_information": [
        {
          "code": "3600502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 156.6908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VEIN HARVEST VASOVIEW",
      "code_information": [
        {
          "code": "3600503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1476,
          "minimum": 309.96,
          "maximum": 1080.7272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1080.7272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURSPLEX DART300 NASAL",
      "code_information": [
        {
          "code": "3600506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.1116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CURAPLEX DART-REACH600",
      "code_information": [
        {
          "code": "3600507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 140,
          "minimum": 29.4,
          "maximum": 102.508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 102.508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY O40-403",
      "code_information": [
        {
          "code": "3600508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 4.6X340 P99-110-4634",
      "code_information": [
        {
          "code": "3600519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2049.4278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 11X200 4922-8-200",
      "code_information": [
        {
          "code": "3600545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1786,
          "minimum": 375.06,
          "maximum": 1307.7092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1307.7092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HEMOCON PERF 020271801",
      "code_information": [
        {
          "code": "3600548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 842,
          "minimum": 176.82,
          "maximum": 616.5124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 616.5124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-SINGLE NEOPRENE M8138",
      "code_information": [
        {
          "code": "3600550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV EXTRICATION PED",
      "code_information": [
        {
          "code": "3600552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DIFFUSICS IV 20G 383592",
      "code_information": [
        {
          "code": "3600553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 123,
          "minimum": 25.83,
          "maximum": 90.0606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.0606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-EAR DISP 4015",
      "code_information": [
        {
          "code": "3600557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 302,
          "minimum": 63.42,
          "maximum": 221.1244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 221.1244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG STRT AR-7821",
      "code_information": [
        {
          "code": "3600561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1216.1842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 10FL AR-9280NOT",
      "code_information": [
        {
          "code": "3600562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 811.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-NANO 2.8X11 AR-9280NSR",
      "code_information": [
        {
          "code": "3600563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1108,
          "minimum": 232.68,
          "maximum": 811.2776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 811.2776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-HP EVAC 70 E1CA5874-01",
      "code_information": [
        {
          "code": "3600565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2197,
          "minimum": 461.37,
          "maximum": 1608.6434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1608.6434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-EVAC 70 EICA5872-01",
      "code_information": [
        {
          "code": "3600567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2097,
          "minimum": 440.37,
          "maximum": 1535.4234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1535.4234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE XP EICA8872-01",
      "code_information": [
        {
          "code": "3600568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2093,
          "minimum": 439.53,
          "maximum": 1532.4946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1532.4946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PURPLE",
      "code_information": [
        {
          "code": "3600570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY PURPLE",
      "code_information": [
        {
          "code": "3600571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-IV DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION PINK/RED",
      "code_information": [
        {
          "code": "3600574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY YELLOW",
      "code_information": [
        {
          "code": "3600575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY WHITE",
      "code_information": [
        {
          "code": "3600576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION WHITE",
      "code_information": [
        {
          "code": "3600577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY BLUE",
      "code_information": [
        {
          "code": "3600578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION BLUE",
      "code_information": [
        {
          "code": "3600579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION ORANGE",
      "code_information": [
        {
          "code": "3600580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY ORANGE",
      "code_information": [
        {
          "code": "3600581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-INTUBATION GREEN",
      "code_information": [
        {
          "code": "3600582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-OXYGEN DELIVERY GREEN",
      "code_information": [
        {
          "code": "3600583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GUIDE 95CM/9FR STRT",
      "code_information": [
        {
          "code": "3600599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1395.5732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 16MM P45-914-0001",
      "code_information": [
        {
          "code": "3600607",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-XL 10MM HEX P45-941-0001",
      "code_information": [
        {
          "code": "3600609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 498.6282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT P45-170-1000",
      "code_information": [
        {
          "code": "3600610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4946.7432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MEASURE STOMA MIC-KEY",
      "code_information": [
        {
          "code": "3600617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 91,
          "minimum": 19.11,
          "maximum": 66.6302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.6302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENTERAL FEEDING LITE",
      "code_information": [
        {
          "code": "3600618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 138,
          "minimum": 28.98,
          "maximum": 101.0436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 101.0436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-FARREL ENTERAL W BAG",
      "code_information": [
        {
          "code": "3600619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 126,
          "minimum": 26.46,
          "maximum": 92.2572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 92.2572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-1.7MM AR-7511",
      "code_information": [
        {
          "code": "3600664",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 WHITE 48360W",
      "code_information": [
        {
          "code": "3600665",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1186.8962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLUE 48360B",
      "code_information": [
        {
          "code": "3600666",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1186.8962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 GREEN 48360G",
      "code_information": [
        {
          "code": "3600667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1186.8962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE 60 BLACK 48360T",
      "code_information": [
        {
          "code": "3600668",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1621,
          "minimum": 340.41,
          "maximum": 1186.8962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1186.8962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUCTION-PORTABLE DEVILBISS",
      "code_information": [
        {
          "code": "3600669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2011,
          "minimum": 422.31,
          "maximum": 1472.4542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1472.4542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WATER-STERILE INHALATION 500ML",
      "code_information": [
        {
          "code": "3600670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-14FR SU130-1239",
      "code_information": [
        {
          "code": "3600671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2016,
          "minimum": 423.36,
          "maximum": 1476.1152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1476.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "T-TUBE-16FR SU130-1240",
      "code_information": [
        {
          "code": "3600672",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2016,
          "minimum": 423.36,
          "maximum": 1476.1152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1476.1152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X185MM 2351-4218S",
      "code_information": [
        {
          "code": "3600681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 951.86,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 1.7MM DSDS0017",
      "code_information": [
        {
          "code": "3600688",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1395.5732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 2MM DSDS0020",
      "code_information": [
        {
          "code": "3600689",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1395.5732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3600708",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 762.9524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.6X150MM AR-8741-16",
      "code_information": [
        {
          "code": "3600710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 449.5708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR,-TR 2X8MM AR-300-B002",
      "code_information": [
        {
          "code": "3600711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1806.3374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.4X3.5MM AR-8741-14",
      "code_information": [
        {
          "code": "3600715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 609,
          "minimum": 127.89,
          "maximum": 445.9098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 445.9098,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION AR-200",
      "code_information": [
        {
          "code": "3600717",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 288.4868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-3.7MM DRILL AR-2272",
      "code_information": [
        {
          "code": "3600719",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1425,
          "minimum": 299.25,
          "maximum": 1043.385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1043.385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO POLY M-L 51114V",
      "code_information": [
        {
          "code": "3600722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 78,
          "minimum": 16.38,
          "maximum": 57.1116,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.1116,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CADD PCA 108” 21-7391-24",
      "code_information": [
        {
          "code": "3600723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 168,
          "minimum": 35.28,
          "maximum": 123.0096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 123.0096,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.0 KWIRE 03.130.102",
      "code_information": [
        {
          "code": "3600736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 X806H",
      "code_information": [
        {
          "code": "3600739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 96,
          "minimum": 20.16,
          "maximum": 70.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 70.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN PVC 24FR",
      "code_information": [
        {
          "code": "3600749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANCHOR-ENTUIT SUTURE G35562",
      "code_information": [
        {
          "code": "3600750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1342,
          "minimum": 281.82,
          "maximum": 982.6124,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 982.6124,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT FEEDINGTUBE G3561",
      "code_information": [
        {
          "code": "3600751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 776,
          "minimum": 162.96,
          "maximum": 568.1872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 568.1872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LEAD-CATH 4FR 38 383069",
      "code_information": [
        {
          "code": "3600757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-NITINOL 2.0MM",
      "code_information": [
        {
          "code": "3600759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6MM MXM-072-16",
      "code_information": [
        {
          "code": "3600767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1317.2278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.6 MXM-072-ISO-16",
      "code_information": [
        {
          "code": "3600768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1317.2278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RCC RMH-T015S",
      "code_information": [
        {
          "code": "3600773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 661.9088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXOFIN FUSION EF70430",
      "code_information": [
        {
          "code": "3600781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 976,
          "minimum": 204.96,
          "maximum": 714.6272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 714.6272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 MONOTEX FS-2 T8665",
      "code_information": [
        {
          "code": "3600782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 112,
          "minimum": 23.52,
          "maximum": 82.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA",
      "code_information": [
        {
          "code": "3600783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 395.388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "XTRAFLANGE-PROVOX 20 FR 7276",
      "code_information": [
        {
          "code": "3600784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 540,
          "minimum": 113.4,
          "maximum": 395.388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 395.388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20 FR 6MM 8277",
      "code_information": [
        {
          "code": "3600785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1951,
          "minimum": 409.71,
          "maximum": 1428.5222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1428.5222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2006-NS",
      "code_information": [
        {
          "code": "3600786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2136.5596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-NS",
      "code_information": [
        {
          "code": "3600787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2136.5596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-BLOM-SINGER DV2010-LF",
      "code_information": [
        {
          "code": "3600788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2918,
          "minimum": 612.78,
          "maximum": 2136.5596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2136.5596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE 4.2X130 2351-4213S",
      "code_information": [
        {
          "code": "3600791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 951.86,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-LOCK 4.2X360 2351-4236S",
      "code_information": [
        {
          "code": "3600792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1300,
          "minimum": 273,
          "maximum": 951.86,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 951.86,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-CARDIOTOMY EL400",
      "code_information": [
        {
          "code": "3600858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 579,
          "minimum": 121.59,
          "maximum": 423.9438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 423.9438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 34CC LINEAR",
      "code_information": [
        {
          "code": "3600866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4523,
          "minimum": 949.83,
          "maximum": 3311.7406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3311.7406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 40CC MEGA 0",
      "code_information": [
        {
          "code": "3600867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4905,
          "minimum": 1030.05,
          "maximum": 3591.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3591.441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON 7.5FR 50CC MEGA 0",
      "code_information": [
        {
          "code": "3600868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4905,
          "minimum": 1030.05,
          "maximum": 3591.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3591.441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-8\\\" THD AR-8967KT",
      "code_information": [
        {
          "code": "3600879",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1 LMA",
      "code_information": [
        {
          "code": "3600899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PENCIL-SMOKE EVAC 10' 251010J",
      "code_information": [
        {
          "code": "3600900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-STR 4MM P1-AU511",
      "code_information": [
        {
          "code": "3600906",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7067,
          "minimum": 1484.07,
          "maximum": 5174.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5174.4574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 1.5 LMA",
      "code_information": [
        {
          "code": "3600907",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 3 LMA",
      "code_information": [
        {
          "code": "3600908",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 5 LMA",
      "code_information": [
        {
          "code": "3600909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AURASTRAIGHT SIZE 2 LMA",
      "code_information": [
        {
          "code": "3600910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 73,
          "minimum": 15.33,
          "maximum": 53.4506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.4506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS MED TRACTION",
      "code_information": [
        {
          "code": "3600912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS LG TRACTION",
      "code_information": [
        {
          "code": "3600913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-BUCKS SM TRACTION",
      "code_information": [
        {
          "code": "3600914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 276,
          "minimum": 57.96,
          "maximum": 202.0872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.0872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SHRT SCREW 6149.1042",
      "code_information": [
        {
          "code": "3600925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EZX 54MM BRXTB540",
      "code_information": [
        {
          "code": "3600938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5636,
          "minimum": 1183.56,
          "maximum": 4126.6792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4126.6792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BARRIER-TOGA XL 0416-830-100",
      "code_information": [
        {
          "code": "3600948",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 909,
          "minimum": 190.89,
          "maximum": 665.5698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 665.5698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VEGA-PROVOX 20F 10MM 8279",
      "code_information": [
        {
          "code": "3600952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1894,
          "minimum": 397.74,
          "maximum": 1386.7868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1386.7868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CELERIS MALLEABLE 4MM",
      "code_information": [
        {
          "code": "3600954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2175,
          "minimum": 456.75,
          "maximum": 1592.535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1592.535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG LIGHT MED C02051",
      "code_information": [
        {
          "code": "3600964",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 80.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULUM-VAG SMALL C020500",
      "code_information": [
        {
          "code": "3600965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 228MM 56010228",
      "code_information": [
        {
          "code": "3600977",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-JONES 3.2MM 56013200",
      "code_information": [
        {
          "code": "3600978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1395.5732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-CANN 5.5MM 56015500",
      "code_information": [
        {
          "code": "3600980",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1584,
          "minimum": 332.64,
          "maximum": 1159.8048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1159.8048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-CRYOTHERAPY FGS-7000",
      "code_information": [
        {
          "code": "3600997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5867,
          "minimum": 1232.07,
          "maximum": 4295.8174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4295.8174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-EXHAUST COLLECT FGS-7015",
      "code_information": [
        {
          "code": "3600999",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONN-X 5.5/32-40 LNG 1119.0034",
      "code_information": [
        {
          "code": "3601000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3188,
          "minimum": 669.48,
          "maximum": 2334.2536,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2334.2536,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-SUCT&ANTICOAG BT275",
      "code_information": [
        {
          "code": "3601009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 196,
          "minimum": 41.16,
          "maximum": 143.5112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 143.5112,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-INJ XF 4.2MM 0909-400-400",
      "code_information": [
        {
          "code": "3601031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 512.54,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 10MM 650.110",
      "code_information": [
        {
          "code": "3601032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-12\\\" THD AR-8967KT-12",
      "code_information": [
        {
          "code": "3601044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 275.3072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CRV 4MM P1-AU550",
      "code_information": [
        {
          "code": "3601055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5762.414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-360-430 ALLOX2-FH13SE",
      "code_information": [
        {
          "code": "3601056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7446,
          "minimum": 1563.66,
          "maximum": 5451.9612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5451.9612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-THORACENTESIS/PARACENTESI",
      "code_information": [
        {
          "code": "3601066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 701,
          "minimum": 147.21,
          "maximum": 513.2722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 513.2722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-11G CMNT 0306-150-000",
      "code_information": [
        {
          "code": "3601086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.8556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CMNT 11G 0306-330-000",
      "code_information": [
        {
          "code": "3601087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 642,
          "minimum": 134.82,
          "maximum": 470.0724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 470.0724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IRRIGATION TB AR-200",
      "code_information": [
        {
          "code": "3601096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 297.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRILL 3X320 P31-951-3032",
      "code_information": [
        {
          "code": "3601107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1963,
          "minimum": 412.23,
          "maximum": 1437.3086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1437.3086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 7X200 P99-110-7019",
      "code_information": [
        {
          "code": "3601108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2049.4278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-110-4630",
      "code_information": [
        {
          "code": "3601109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2049.4278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-3.8X250 P99-100-3825",
      "code_information": [
        {
          "code": "3601110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2049.4278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.6X300 P99-100-4630",
      "code_information": [
        {
          "code": "3601111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2049.4278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-HEAD 17.5 03.404.031S",
      "code_information": [
        {
          "code": "3601120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3893,
          "minimum": 817.53,
          "maximum": 2850.4546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2850.4546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CENTRAL VENOUS PED",
      "code_information": [
        {
          "code": "3601123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 669,
          "minimum": 140.49,
          "maximum": 489.8418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 489.8418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOD-PROTECTOR 69392",
      "code_information": [
        {
          "code": "3601124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 350,
          "minimum": 73.5,
          "maximum": 256.27,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 256.27,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT ADULT DISP 731",
      "code_information": [
        {
          "code": "3601125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 273,
          "minimum": 57.33,
          "maximum": 199.8906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 199.8906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CHEST VENT HYFIN TWINPACK",
      "code_information": [
        {
          "code": "3601126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 126.6706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-VARISPEED 62-50201",
      "code_information": [
        {
          "code": "3601154",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1913,
          "minimum": 401.73,
          "maximum": 1400.6986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1400.6986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.5MM 72202189",
      "code_information": [
        {
          "code": "3601200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STR 14MM/SC 684.424",
      "code_information": [
        {
          "code": "3601216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-SUCTION BALLARD 14FR",
      "code_information": [
        {
          "code": "3601234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 35FR 412351000",
      "code_information": [
        {
          "code": "3601235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1253.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 37FR 412371000",
      "code_information": [
        {
          "code": "3601236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1277.689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VIVASIGHT 39FR 412391000",
      "code_information": [
        {
          "code": "3601237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1277.689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-1.8X450 DIA PT 4933-8-010",
      "code_information": [
        {
          "code": "3601244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 682,
          "minimum": 143.22,
          "maximum": 499.3604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 499.3604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 120MM 4933-1-120",
      "code_information": [
        {
          "code": "3601245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 527,
          "minimum": 110.67,
          "maximum": 385.8694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 385.8694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-THRD 150MM 4933-1-150",
      "code_information": [
        {
          "code": "3601246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 527,
          "minimum": 110.67,
          "maximum": 385.8694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 385.8694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-F/4MM SCREW 6149.1040",
      "code_information": [
        {
          "code": "3601255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-IV SW 3000ML BAG S8505",
      "code_information": [
        {
          "code": "3601260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 150,
          "minimum": 31.5,
          "maximum": 109.83,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.83,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-4MM CANN AR-8973-40S",
      "code_information": [
        {
          "code": "3601272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1143.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-PIN & PROT P45-610-1000",
      "code_information": [
        {
          "code": "3601289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 415,
          "minimum": 87.15,
          "maximum": 303.863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 303.863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-10MM P47-950-0001",
      "code_information": [
        {
          "code": "3601290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1933,
          "minimum": 405.93,
          "maximum": 1415.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1415.3426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-PROTECT P45-600-1000-S",
      "code_information": [
        {
          "code": "3601291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 152.2976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-AIR+MENISCAL CV 4722",
      "code_information": [
        {
          "code": "3601324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2551,
          "minimum": 535.71,
          "maximum": 1867.8422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1867.8422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-BLUE STAPLE GCR40B",
      "code_information": [
        {
          "code": "3601345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1903,
          "minimum": 399.63,
          "maximum": 1393.3766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1393.3766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-GRAFT LG M00236320021",
      "code_information": [
        {
          "code": "3601349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 176,
          "minimum": 36.96,
          "maximum": 128.8672,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 128.8672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC SMALL 313-9013W",
      "code_information": [
        {
          "code": "3601350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 207.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC MED 313-9014W",
      "code_information": [
        {
          "code": "3601351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 207.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BITRAC LARGE 313-9015W",
      "code_information": [
        {
          "code": "3601352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 283,
          "minimum": 59.43,
          "maximum": 207.2126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 207.2126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-2.5 PRCSN MTCH HD 16CM",
      "code_information": [
        {
          "code": "3601354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1891,
          "minimum": 397.11,
          "maximum": 1384.5902,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1384.5902,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TROCH 1.1MM AR-18700-30",
      "code_information": [
        {
          "code": "3601375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.1956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STEP SOLID 1806-3026S",
      "code_information": [
        {
          "code": "3601387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1432,
          "minimum": 300.72,
          "maximum": 1048.5104,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1048.5104,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47522",
      "code_information": [
        {
          "code": "3601390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 917.4466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-TORNADO G47520",
      "code_information": [
        {
          "code": "3601391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 917.4466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-ENDOCLOT EA230",
      "code_information": [
        {
          "code": "3601393",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 592,
          "minimum": 124.32,
          "maximum": 433.4624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 433.4624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 12\\\" 3.2MM",
      "code_information": [
        {
          "code": "3601397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 399,
          "minimum": 83.79,
          "maximum": 292.1478,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 292.1478,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.25MM  AR-18800-35",
      "code_information": [
        {
          "code": "3601403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 851,
          "minimum": 178.71,
          "maximum": 623.1022,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 623.1022,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-10X16X8/12° 1213.6088S",
      "code_information": [
        {
          "code": "3601406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6769,
          "minimum": 1421.49,
          "maximum": 4956.2618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4956.2618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 16X8MM 1128.2408",
      "code_information": [
        {
          "code": "3601407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3304.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X14MM 184.014",
      "code_information": [
        {
          "code": "3601408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR ST 4.2X16MM 184.016",
      "code_information": [
        {
          "code": "3601409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-VR SD 4.2X14MM 184.054",
      "code_information": [
        {
          "code": "3601410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 18FR 8887605189",
      "code_information": [
        {
          "code": "3601420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 20FR 8887605205",
      "code_information": [
        {
          "code": "3601421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-IN/OUTFLOW AR-6436",
      "code_information": [
        {
          "code": "3601433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1031,
          "minimum": 216.51,
          "maximum": 754.8982,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 754.8982,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-3X7 AR-9300DS",
      "code_information": [
        {
          "code": "3601434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 605.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 614,
          "minimum": 128.94,
          "maximum": 449.5708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 449.5708,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON PEG ENFIT",
      "code_information": [
        {
          "code": "3601438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.0234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G-TUBE ENFIT",
      "code_information": [
        {
          "code": "3601440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1234,
          "minimum": 259.14,
          "maximum": 903.5348,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 903.5348,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG ENFIT 24FR M00509061",
      "code_information": [
        {
          "code": "3601441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 706,
          "minimum": 148.26,
          "maximum": 516.9332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 516.9332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5020",
      "code_information": [
        {
          "code": "3601445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 846,
          "minimum": 177.66,
          "maximum": 619.4412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 619.4412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOCKWAVE STERILE CABLE",
      "code_information": [
        {
          "code": "3601446",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16FR 20CM G01212",
      "code_information": [
        {
          "code": "3601447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-18FR 20CM G01328",
      "code_information": [
        {
          "code": "3601448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO JEJUNAL 8250-22",
      "code_information": [
        {
          "code": "3601452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1577,
          "minimum": 331.17,
          "maximum": 1154.6794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1154.6794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNAL 20FR 8200-20",
      "code_information": [
        {
          "code": "3601453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1384,
          "minimum": 290.64,
          "maximum": 1013.3648,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1013.3648,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10FR 50-7361",
      "code_information": [
        {
          "code": "3601454",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 444,
          "minimum": 93.24,
          "maximum": 325.0968,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 325.0968,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO 18140",
      "code_information": [
        {
          "code": "3601455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 717.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCANN 2.55MM MD 45303155",
      "code_information": [
        {
          "code": "3601456",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-DLP CORONARY 30315",
      "code_information": [
        {
          "code": "3601479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 510,
          "minimum": 107.1,
          "maximum": 373.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 373.422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEG PULL SAFE 20F ENFIT",
      "code_information": [
        {
          "code": "3601480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 875,
          "minimum": 183.75,
          "maximum": 640.675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 640.675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 14FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.0234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BALLOON 16FR PEG ENFIT",
      "code_information": [
        {
          "code": "3601482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.0234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC DRG MN12050",
      "code_information": [
        {
          "code": "3601484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2685,
          "minimum": 563.85,
          "maximum": 1965.957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1965.957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PREFORM-S3-4 39+6MM DWP2396",
      "code_information": [
        {
          "code": "3601576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8123,
          "minimum": 1705.83,
          "maximum": 5947.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5947.6606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AGX RP 18X7MM 1128.1507",
      "code_information": [
        {
          "code": "3601577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3304.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPACER-20X55 8-17 5° 1122.1055",
      "code_information": [
        {
          "code": "3601578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 31589,
          "minimum": 6633.69,
          "maximum": 23129.4658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 23129.4658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 3X14 AR-8630-14",
      "code_information": [
        {
          "code": "3601580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CP/HL 2.5X16 AR-8625-16",
      "code_information": [
        {
          "code": "3601581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LP/CRT 1.6X9 AR-18716-09",
      "code_information": [
        {
          "code": "3601582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1206,
          "minimum": 253.26,
          "maximum": 883.0332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 883.0332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CABLE PLATE 94-1200-08",
      "code_information": [
        {
          "code": "3601588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5867,
          "minimum": 1232.07,
          "maximum": 4295.8174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4295.8174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1195",
      "code_information": [
        {
          "code": "3601590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 703.6442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ1 CN P2ND1001",
      "code_information": [
        {
          "code": "3601591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1101.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDLE-PEDI DSG P2HE2000",
      "code_information": [
        {
          "code": "3601592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8710,
          "minimum": 1829.1,
          "maximum": 6377.462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 6377.462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BALLARD/NEO BAA2103",
      "code_information": [
        {
          "code": "3601615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 115.6876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COMP-DF 65MM/RT/STD 6495-2-040",
      "code_information": [
        {
          "code": "3601630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21681,
          "minimum": 4553.01,
          "maximum": 15874.8282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15874.8282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CN/CC 7X45MM 8040-045",
      "code_information": [
        {
          "code": "3601631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2038.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-SMALL KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7523,
          "minimum": 1579.83,
          "maximum": 5508.3406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5508.3406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASE-LARGE KIT ARTICGEL",
      "code_information": [
        {
          "code": "3601636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7523,
          "minimum": 1579.83,
          "maximum": 5508.3406,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5508.3406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONN 11X100MM 4922-8-100",
      "code_information": [
        {
          "code": "3601641",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1743,
          "minimum": 366.03,
          "maximum": 1276.2246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1276.2246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-WOUND CROWN",
      "code_information": [
        {
          "code": "3601647",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 788,
          "minimum": 165.48,
          "maximum": 576.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 576.9736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN RAL 6MM B02236010",
      "code_information": [
        {
          "code": "3601652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1842.9474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CONN STD 6MM B02236001",
      "code_information": [
        {
          "code": "3601653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1842.9474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-DRILL LK 3.5 AR-8943-43",
      "code_information": [
        {
          "code": "3601667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1960.8316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-ALEXIS M/L HR105",
      "code_information": [
        {
          "code": "3601692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1277.689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5 SHORT 6149.1038S",
      "code_information": [
        {
          "code": "3601700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLEY-COUVEL 3-W",
      "code_information": [
        {
          "code": "3601705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-O3 OXIMETRY CEREBRAL",
      "code_information": [
        {
          "code": "3601707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM",
      "code_information": [
        {
          "code": "3601709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1990.1196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-MANTIS 235CM X 2.8MM BOX",
      "code_information": [
        {
          "code": "3601710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2537,
          "minimum": 532.77,
          "maximum": 1857.5914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1857.5914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 23/M P01-900-2303",
      "code_information": [
        {
          "code": "3601722",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1980.601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-PEDI SZ2 CN P2ND1002",
      "code_information": [
        {
          "code": "3601743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1504,
          "minimum": 315.84,
          "maximum": 1101.2288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1101.2288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC-KEY 16FR",
      "code_information": [
        {
          "code": "3601752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 980,
          "minimum": 205.8,
          "maximum": 717.556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 717.556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PEDIGUARD-CV/XS 4MM P1-AU551",
      "code_information": [
        {
          "code": "3601759",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5762.414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL 3/10F AR-98300OBT",
      "code_information": [
        {
          "code": "3601764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 605.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-CIR/BEV P45-940-1001",
      "code_information": [
        {
          "code": "3601766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.0MM",
      "code_information": [
        {
          "code": "3601769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FLIPCUTTER III AR-1204FF",
      "code_information": [
        {
          "code": "3601777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2543,
          "minimum": 534.03,
          "maximum": 1861.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1861.9846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MGS 3MM AR-9628S",
      "code_information": [
        {
          "code": "3601781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-INFANT NEONATE CO2",
      "code_information": [
        {
          "code": "3601783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 148.6366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-NCAN 4MM AR-1204D",
      "code_information": [
        {
          "code": "3601799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1261,
          "minimum": 264.81,
          "maximum": 923.3042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 923.3042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-.066CN 2.75MM AR-7000-14",
      "code_information": [
        {
          "code": "3601800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1806.3374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X6\\\" AR-8941-6",
      "code_information": [
        {
          "code": "3601803",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .062X7\\\" AR-8941-7",
      "code_information": [
        {
          "code": "3601804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-CRCLG ST TR AR-7823",
      "code_information": [
        {
          "code": "3601805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1216.1842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TROCH 1.35MM AR-8737-02",
      "code_information": [
        {
          "code": "3601814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 314,
          "minimum": 65.94,
          "maximum": 229.9108,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.9108,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-SPRAY AR-200SP",
      "code_information": [
        {
          "code": "3601873",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1449.756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G MIS SHARP 501168",
      "code_information": [
        {
          "code": "3601880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARVESTER-BONE 6MM BH-220",
      "code_information": [
        {
          "code": "3601882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 11846,
          "minimum": 2487.66,
          "maximum": 8673.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8673.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMAN.157X9\\\" KI71675",
      "code_information": [
        {
          "code": "3601893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 193,
          "minimum": 40.53,
          "maximum": 141.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 141.3146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .035X9\\\" DD KI71211",
      "code_information": [
        {
          "code": "3601894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FRACTURE KEX152EB",
      "code_information": [
        {
          "code": "3601895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 13504,
          "minimum": 2835.84,
          "maximum": 9887.6288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 9887.6288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-TIB 11X360MM 1822-1136S",
      "code_information": [
        {
          "code": "3601898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5142,
          "minimum": 1079.82,
          "maximum": 3764.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3764.9724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-LASER TRACH #5 102004050",
      "code_information": [
        {
          "code": "3601900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1245,
          "minimum": 261.45,
          "maximum": 911.589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 911.589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-BLOOD COLLECT 04258",
      "code_information": [
        {
          "code": "3601933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 585,
          "minimum": 122.85,
          "maximum": 428.337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 428.337,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA BLUNT 20FR 77720",
      "code_information": [
        {
          "code": "3601934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 744,
          "minimum": 156.24,
          "maximum": 544.7568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 544.7568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .062X5\\\" 5050-249",
      "code_information": [
        {
          "code": "3601939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 143,
          "minimum": 30.03,
          "maximum": 104.7046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 104.7046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-C TR TIP .045X5\\\" 5050-248",
      "code_information": [
        {
          "code": "3601940",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 103,
          "minimum": 21.63,
          "maximum": 75.4166,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 75.4166,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLUTION-WOUND VASHE 16OZ 003",
      "code_information": [
        {
          "code": "3601945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX944",
      "code_information": [
        {
          "code": "3601947",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 278,
          "minimum": 58.38,
          "maximum": 203.5516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 203.5516,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-4MM AO 702473",
      "code_information": [
        {
          "code": "3601950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2131,
          "minimum": 447.51,
          "maximum": 1560.3182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1560.3182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-7MM P20-910-7000",
      "code_information": [
        {
          "code": "3601961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1261.5806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXT-PERCUTANEOUS 9009",
      "code_information": [
        {
          "code": "3601976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 400MM BT 693.060S",
      "code_information": [
        {
          "code": "3601978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 384.405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM 1032-115-000",
      "code_information": [
        {
          "code": "3601985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10370,
          "minimum": 2177.7,
          "maximum": 7592.914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7592.914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM 2PROBE 9700-020-200",
      "code_information": [
        {
          "code": "3601986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 20104,
          "minimum": 4221.84,
          "maximum": 14720.1488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 14720.1488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-AEOS STERILE PV012SU",
      "code_information": [
        {
          "code": "3601989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 462,
          "minimum": 97.02,
          "maximum": 338.2764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 338.2764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-EOPA 22FR 77422",
      "code_information": [
        {
          "code": "3601990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 559,
          "minimum": 117.39,
          "maximum": 409.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 409.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ENDO 5MM 174209",
      "code_information": [
        {
          "code": "3601996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1819,
          "minimum": 381.99,
          "maximum": 1331.8718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1331.8718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 6213-119-070",
      "code_information": [
        {
          "code": "3601997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-CHIN PURESOME TMD-07",
      "code_information": [
        {
          "code": "3601998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 255.5378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3MM AR-8943-36",
      "code_information": [
        {
          "code": "3602028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1198,
          "minimum": 251.58,
          "maximum": 877.1756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 877.1756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-PED LUMBAR 21G 645",
      "code_information": [
        {
          "code": "3602032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 219,
          "minimum": 45.99,
          "maximum": 160.3518,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 160.3518,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X C/D",
      "code_information": [
        {
          "code": "3602043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X C/D",
      "code_information": [
        {
          "code": "3602044",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 210.8736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X C/D",
      "code_information": [
        {
          "code": "3602045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.0734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL C/D",
      "code_information": [
        {
          "code": "3602046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.0734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG C/D",
      "code_information": [
        {
          "code": "3602047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.0734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED C/D",
      "code_information": [
        {
          "code": "3602048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.0734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K SMALL C/D",
      "code_information": [
        {
          "code": "3602049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 4X A/B",
      "code_information": [
        {
          "code": "3602050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 3X A/B",
      "code_information": [
        {
          "code": "3602051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K 2X A/B",
      "code_information": [
        {
          "code": "3602052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 288,
          "minimum": 60.48,
          "maximum": 210.8736,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 210.8736,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K XL A/B",
      "code_information": [
        {
          "code": "3602053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.0734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K LRG A/B",
      "code_information": [
        {
          "code": "3602054",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 347,
          "minimum": 72.87,
          "maximum": 254.0734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 254.0734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HANNAH 2160K MED A/B",
      "code_information": [
        {
          "code": "3602055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN CMP 2.2 DSDS0022",
      "code_information": [
        {
          "code": "3602079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1906,
          "minimum": 400.26,
          "maximum": 1395.5732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1395.5732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-JOINT PREP INST 9914PK01",
      "code_information": [
        {
          "code": "3602083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2349,
          "minimum": 493.29,
          "maximum": 1719.9378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1719.9378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP 1.1 NT/SM 58820006",
      "code_information": [
        {
          "code": "3602084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 752,
          "minimum": 157.92,
          "maximum": 550.6144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 550.6144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MICA 2X12MM 57SR0212",
      "code_information": [
        {
          "code": "3602085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2772,
          "minimum": 582.12,
          "maximum": 2029.6584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2029.6584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-MICA INST BLADE 57S1MI07",
      "code_information": [
        {
          "code": "3602088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2242,
          "minimum": 470.82,
          "maximum": 1641.5924,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1641.5924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-PILLCAMPATNCY FGS-0668",
      "code_information": [
        {
          "code": "3602103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPRAY-BIENAIR AQUACARE 1600617",
      "code_information": [
        {
          "code": "3602106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-ORGO IRRIGATION 1502152",
      "code_information": [
        {
          "code": "3602107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 261,
          "minimum": 54.81,
          "maximum": 191.1042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 191.1042,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POUCH-OSTOMY 18665",
      "code_information": [
        {
          "code": "3602109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-CLOSED TUBE 1320-0125S",
      "code_information": [
        {
          "code": "3602113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 959,
          "minimum": 201.39,
          "maximum": 702.1798,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 702.1798,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0 724G",
      "code_information": [
        {
          "code": "3602121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 60,
          "minimum": 12.6,
          "maximum": 43.932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0 8756H",
      "code_information": [
        {
          "code": "3602122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.8268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0   8717H",
      "code_information": [
        {
          "code": "3602124",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 153.0298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-EVARREST 2x4\\\" EVT5024",
      "code_information": [
        {
          "code": "3602126",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4700,
          "minimum": 987,
          "maximum": 3441.34,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3441.34,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-6 LEAD ECG SNAP BR-916PA",
      "code_information": [
        {
          "code": "3602128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1080,
          "minimum": 226.8,
          "maximum": 790.776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 790.776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE",
      "code_information": [
        {
          "code": "3602129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1295,
          "minimum": 271.95,
          "maximum": 948.199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 948.199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-TRI 4.0MM P1-AU411",
      "code_information": [
        {
          "code": "3602153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7067,
          "minimum": 1484.07,
          "maximum": 5174.4574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5174.4574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1277.689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602176",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.2594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1003.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2038.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 839.1012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0 C012D",
      "code_information": [
        {
          "code": "3602196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 164,
          "minimum": 34.44,
          "maximum": 120.0808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 120.0808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1216.1842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2949.3016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1277.689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602233",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.2594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1003.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602236",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2038.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 839.1012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL-FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3164,
          "minimum": 664.44,
          "maximum": 2316.6808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2316.6808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2949.3016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1216.1842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-END +5 HUM 1830-0005S",
      "code_information": [
        {
          "code": "3602288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1128,
          "minimum": 236.88,
          "maximum": 825.9216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 825.9216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1277.689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.2594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602298",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1003.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2785,
          "minimum": 584.85,
          "maximum": 2039.177,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2039.177,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 839.1012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT DL 15MM PROBE 9700-015-200",
      "code_information": [
        {
          "code": "3602331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 22350,
          "minimum": 4693.5,
          "maximum": 16364.67,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 16364.67,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CY SCUL 3X12MM 58SC3012",
      "code_information": [
        {
          "code": "3602334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2949.3016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AWL FENSTRATION 58FENAWL",
      "code_information": [
        {
          "code": "3602336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3164,
          "minimum": 664.44,
          "maximum": 2316.6808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2316.6808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602339",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2185,
          "minimum": 458.85,
          "maximum": 1599.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1599.857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR CART 3X12MM CYL 58CC3012",
      "code_information": [
        {
          "code": "3602348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4028,
          "minimum": 845.88,
          "maximum": 2949.3016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2949.3016,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER STRT SM AR-7825",
      "code_information": [
        {
          "code": "3602350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1661,
          "minimum": 348.81,
          "maximum": 1216.1842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1216.1842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.4X150 BL DSDS1014S",
      "code_information": [
        {
          "code": "3602369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 3X60MM 57S00030",
      "code_information": [
        {
          "code": "3602372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1745,
          "minimum": 366.45,
          "maximum": 1277.689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1277.689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL CN 2.2MM HT 45303025",
      "code_information": [
        {
          "code": "3602373",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE SAW SAG 2108-107-009",
      "code_information": [
        {
          "code": "3602375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 477,
          "minimum": 100.17,
          "maximum": 349.2594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.2594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL ACTIVATION S0457-000",
      "code_information": [
        {
          "code": "3602376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1003.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 4X280MM CAL S0219-100",
      "code_information": [
        {
          "code": "3602377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL 5MM AO CAL S0209-200",
      "code_information": [
        {
          "code": "3602378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2784,
          "minimum": 584.64,
          "maximum": 2038.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2038.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2MM LNG AR-8963-05",
      "code_information": [
        {
          "code": "3602391",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 839.1012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT 125MM NANO AR-3210-0050",
      "code_information": [
        {
          "code": "3602398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5426,
          "minimum": 1139.46,
          "maximum": 3972.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3972.9172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK K-WIRE LAP 57KWPACK",
      "code_information": [
        {
          "code": "3602402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2185,
          "minimum": 458.85,
          "maximum": 1599.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1599.857,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK DRILL 5MM 57DRDEP5",
      "code_information": [
        {
          "code": "3602403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5426,
          "minimum": 1139.46,
          "maximum": 3972.9172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3972.9172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 13MM 7786713",
      "code_information": [
        {
          "code": "3602404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TEMP FIXATION 7786703",
      "code_information": [
        {
          "code": "3602405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-MDI SPACER M 1082715",
      "code_information": [
        {
          "code": "3602410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 105,
          "minimum": 22.05,
          "maximum": 76.881,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-STEALTH SZ5/90MM A0A14",
      "code_information": [
        {
          "code": "3602422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON LINEAR 40",
      "code_information": [
        {
          "code": "3602462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5202,
          "minimum": 1092.42,
          "maximum": 3808.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3808.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IRRIGATION 111331",
      "code_information": [
        {
          "code": "3602483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 707.3052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SKIN CLOSURE CLR602US",
      "code_information": [
        {
          "code": "3602486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1556,
          "minimum": 326.76,
          "maximum": 1139.3032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1139.3032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-RADIAN FACET K 5526061",
      "code_information": [
        {
          "code": "3602487",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1514,
          "minimum": 317.94,
          "maximum": 1108.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1108.5508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-ACP 11MM 7786711",
      "code_information": [
        {
          "code": "3602491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PELVIC STAB T-PODR",
      "code_information": [
        {
          "code": "3602497",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 935,
          "minimum": 196.35,
          "maximum": 684.607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 684.607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIR-G BL-NOSE 3X900 0101-900S",
      "code_information": [
        {
          "code": "3602503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1253,
          "minimum": 263.13,
          "maximum": 917.4466,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 917.4466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165MM S0210-200",
      "code_information": [
        {
          "code": "3602508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1940,
          "minimum": 407.4,
          "maximum": 1420.468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1420.468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-OPEN REAMER 03.168.004",
      "code_information": [
        {
          "code": "3602515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 8067,
          "minimum": 1694.07,
          "maximum": 5906.6574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5906.6574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.3X413MM 03.168.011",
      "code_information": [
        {
          "code": "3602516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3163,
          "minimum": 664.23,
          "maximum": 2315.9486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2315.9486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LOWER 8/+0 END 2330-0000S",
      "code_information": [
        {
          "code": "3602538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1299,
          "minimum": 272.79,
          "maximum": 951.1278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 951.1278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HEART LOOP AV 9S44R",
      "code_information": [
        {
          "code": "3602540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 525,
          "minimum": 110.25,
          "maximum": 384.405,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 384.405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-LOW PROFILE 6143.2527",
      "code_information": [
        {
          "code": "3602541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6702,
          "minimum": 1407.42,
          "maximum": 4907.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4907.2044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 160MM P45-180-0160",
      "code_information": [
        {
          "code": "3602542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4045,
          "minimum": 849.45,
          "maximum": 2961.749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2961.749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 160MM P45-112-0140",
      "code_information": [
        {
          "code": "3602543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4946.7432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-G BALL 3X550 P31-955-1550",
      "code_information": [
        {
          "code": "3602544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1963,
          "minimum": 412.23,
          "maximum": 1437.3086,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1437.3086,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-300MM THRED P45-310-0300",
      "code_information": [
        {
          "code": "3602545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRUTS-QA MOD MD P45-224-0170",
      "code_information": [
        {
          "code": "3602546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6214,
          "minimum": 1304.94,
          "maximum": 4549.8908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4549.8908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INST ARAGONITE MINI-DS",
      "code_information": [
        {
          "code": "3602550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1474.6508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JOINT-BALL MOD P45-233-1000",
      "code_information": [
        {
          "code": "3602557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE 1.8 P99-202-1810",
      "code_information": [
        {
          "code": "3602569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 779.793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 0 VCPP41D",
      "code_information": [
        {
          "code": "3602572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 181,
          "minimum": 38.01,
          "maximum": 132.5282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 132.5282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PRONE LAT STAB 6246.0200",
      "code_information": [
        {
          "code": "3602576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7446,
          "minimum": 1563.66,
          "maximum": 5451.9612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5451.9612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G TT 2.4X9.25 AR-8870K",
      "code_information": [
        {
          "code": "3602593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 235,
          "minimum": 49.35,
          "maximum": 172.067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 172.067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FLUID MANAGEMENT W/CAP",
      "code_information": [
        {
          "code": "3602596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DISP RESECT FLEX 2.9MM",
      "code_information": [
        {
          "code": "3602599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4513,
          "minimum": 947.73,
          "maximum": 3304.4186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3304.4186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3602604",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4897,
          "minimum": 1028.37,
          "maximum": 3585.5834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3585.5834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3602606",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4897,
          "minimum": 1028.37,
          "maximum": 3585.5834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3585.5834,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-3.2L CN AR-8973-32LS",
      "code_information": [
        {
          "code": "3602614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1562,
          "minimum": 328.02,
          "maximum": 1143.6964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1143.6964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°RT AR-4068-90R",
      "code_information": [
        {
          "code": "3602617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1462,
          "minimum": 307.02,
          "maximum": 1070.4764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1070.4764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 90°LT AR-4068-90L",
      "code_information": [
        {
          "code": "3602618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1123.927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°LT AR-4068-45L",
      "code_information": [
        {
          "code": "3602619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1123.927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO 45°RT AR-4068-45R",
      "code_information": [
        {
          "code": "3602620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1123.927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRIPLEDAM AR-6530TD",
      "code_information": [
        {
          "code": "3602621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 293.6122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-DTRAX SPINAL DX-22-300",
      "code_information": [
        {
          "code": "3602622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5077,
          "minimum": 1066.17,
          "maximum": 3717.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3717.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS 11G/5\\\"\\\" 0306-116-000",
      "code_information": [
        {
          "code": "3602624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 774,
          "minimum": 162.54,
          "maximum": 566.7228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 566.7228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-OPTIFIX ABSORB 0113126",
      "code_information": [
        {
          "code": "3602652",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HAWKINS 18GX15CM G05045",
      "code_information": [
        {
          "code": "3602657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 14FR G00996",
      "code_information": [
        {
          "code": "3602678",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 145,
          "minimum": 30.45,
          "maximum": 106.169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-COOK 12FR G00995",
      "code_information": [
        {
          "code": "3602679",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-MWCE-18S-4/2-TORNADO",
      "code_information": [
        {
          "code": "3602685",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1086,
          "minimum": 228.06,
          "maximum": 795.1692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 795.1692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-10-8 MREYE",
      "code_information": [
        {
          "code": "3602686",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 669.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-5-8 MREYE G42423",
      "code_information": [
        {
          "code": "3602687",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 669.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-EMBOLIZATION MREYE G42414",
      "code_information": [
        {
          "code": "3602690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 669.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-5 MREYE G42410",
      "code_information": [
        {
          "code": "3602691",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 669.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-4 MREYE G42409",
      "code_information": [
        {
          "code": "3602692",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 669.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-3-3 MREYE G42408",
      "code_information": [
        {
          "code": "3602693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 669.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-IMWCE-35-2-3 MREYE G42406",
      "code_information": [
        {
          "code": "3602694",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 914,
          "minimum": 191.94,
          "maximum": 669.2308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 669.2308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 15MM X 15G",
      "code_information": [
        {
          "code": "3602699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1426,
          "minimum": 299.46,
          "maximum": 1044.1172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1044.1172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EZ-IO NEEDLE 25MM X 15G",
      "code_information": [
        {
          "code": "3602700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1426,
          "minimum": 299.46,
          "maximum": 1044.1172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1044.1172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CO 2.10MM NS1806.002 STE",
      "code_information": [
        {
          "code": "3602710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1658,
          "minimum": 348.18,
          "maximum": 1213.9876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1213.9876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.4MM 2883-01-024",
      "code_information": [
        {
          "code": "3602763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1645,
          "minimum": 345.45,
          "maximum": 1204.469,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1204.469,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OSC SAW 1.27MM 71440375",
      "code_information": [
        {
          "code": "3602770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 740,
          "minimum": 155.4,
          "maximum": 541.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 541.828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X340MM 1806-4260S",
      "code_information": [
        {
          "code": "3602772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1134,
          "minimum": 238.14,
          "maximum": 830.3148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 830.3148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANN 13X300MM 351.27",
      "code_information": [
        {
          "code": "3602773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3542,
          "minimum": 743.82,
          "maximum": 2593.4524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2593.4524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 360.05S",
      "code_information": [
        {
          "code": "3602774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4064,
          "minimum": 853.44,
          "maximum": 2975.6608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2975.6608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 38FR 68138",
      "code_information": [
        {
          "code": "3602784",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 462,
          "minimum": 97.02,
          "maximum": 338.2764,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 338.2764,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 18G/15CM CA1815",
      "code_information": [
        {
          "code": "3602790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 30FR 68130",
      "code_information": [
        {
          "code": "3602796",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 421.7472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 32FR 68132",
      "code_information": [
        {
          "code": "3602797",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 602,
          "minimum": 126.42,
          "maximum": 440.7844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 440.7844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 36FR 68136",
      "code_information": [
        {
          "code": "3602798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 576,
          "minimum": 120.96,
          "maximum": 421.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 421.7472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 34FR 68134",
      "code_information": [
        {
          "code": "3602799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-CATH TEMP SENSING 18FR",
      "code_information": [
        {
          "code": "3602805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 436,
          "minimum": 91.56,
          "maximum": 319.2392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 319.2392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94895",
      "code_information": [
        {
          "code": "3602818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 762.2202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE 15FR 94835",
      "code_information": [
        {
          "code": "3602819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1041,
          "minimum": 218.61,
          "maximum": 762.2202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 762.2202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 16G/15CM CA1615",
      "code_information": [
        {
          "code": "3602858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY 14G/11CM CA1411",
      "code_information": [
        {
          "code": "3602859",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 513,
          "minimum": 107.73,
          "maximum": 375.6186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.6186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 X523H",
      "code_information": [
        {
          "code": "3602867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0  X513H",
      "code_information": [
        {
          "code": "3602868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 67,
          "minimum": 14.07,
          "maximum": 49.0574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.0574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.7 W/QC STD TP 71933035",
      "code_information": [
        {
          "code": "3602893",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2282,
          "minimum": 479.22,
          "maximum": 1670.8804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1670.8804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.2X250 AO 1806-8018S",
      "code_information": [
        {
          "code": "3602902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 842.03,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-W/ NEEDLES #0 SUTURE",
      "code_information": [
        {
          "code": "3602933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2211.244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-EXTREMITIES UNIVERSAL",
      "code_information": [
        {
          "code": "3602935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-XP STERNALOCK 73-1194",
      "code_information": [
        {
          "code": "3602936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 703.6442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ201",
      "code_information": [
        {
          "code": "3602938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2478.497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EPSILA TUNNELING EAZ101",
      "code_information": [
        {
          "code": "3602939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3385,
          "minimum": 710.85,
          "maximum": 2478.497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2478.497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 180MM P45-112-0180",
      "code_information": [
        {
          "code": "3602943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6756,
          "minimum": 1418.76,
          "maximum": 4946.7432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4946.7432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-ARCH 180MM P45-180-0180",
      "code_information": [
        {
          "code": "3602944",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4045,
          "minimum": 849.45,
          "maximum": 2961.749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2961.749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-4H THRED P45-921-0004",
      "code_information": [
        {
          "code": "3602945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2618,
          "minimum": 549.78,
          "maximum": 1916.8996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1916.8996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CALIBRA 4X165MM 0225-000",
      "code_information": [
        {
          "code": "3602953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2376,
          "minimum": 498.96,
          "maximum": 1739.7072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1739.7072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5MMPINX9.5MMROD 1151-200",
      "code_information": [
        {
          "code": "3602954",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3458,
          "minimum": 726.18,
          "maximum": 2531.9476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2531.9476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-9.5 X 9.5MM ROD 1151-200",
      "code_information": [
        {
          "code": "3602955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3458,
          "minimum": 726.18,
          "maximum": 2531.9476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2531.9476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X150MM 1152-150",
      "code_information": [
        {
          "code": "3602956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X200MM 1152-200",
      "code_information": [
        {
          "code": "3602957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X250MM 1152-250",
      "code_information": [
        {
          "code": "3602958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X300 1152-300",
      "code_information": [
        {
          "code": "3602959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN ASSEM 1158-000",
      "code_information": [
        {
          "code": "3602960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6458,
          "minimum": 1356.18,
          "maximum": 4728.5476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4728.5476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-VENASEAL CLOSURE VS-404",
      "code_information": [
        {
          "code": "3602966",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4936,
          "minimum": 1036.56,
          "maximum": 3614.1392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3614.1392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-5.5 P20-910-5500",
      "code_information": [
        {
          "code": "3602974",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1261.5806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK -.5 P20-915-5500",
      "code_information": [
        {
          "code": "3602976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1261.5806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PROTECT 5.0 P45-198-5000",
      "code_information": [
        {
          "code": "3602978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CORPAK 20F ENFIT 50-5320",
      "code_information": [
        {
          "code": "3603015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1167,
          "minimum": 245.07,
          "maximum": 854.4774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 854.4774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-150MM THRED P45-310-0150",
      "code_information": [
        {
          "code": "3603022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 681,
          "minimum": 143.01,
          "maximum": 498.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 498.6282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RANCHO-CUBE 4H P45-925-0004",
      "code_information": [
        {
          "code": "3603023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2738,
          "minimum": 574.98,
          "maximum": 2004.7636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2004.7636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-3/16\\\" SQ P99-000-316P",
      "code_information": [
        {
          "code": "3603028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-CNT 8MM P45-914-0003",
      "code_information": [
        {
          "code": "3603029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCRW-POST+NUT SET B0223000",
      "code_information": [
        {
          "code": "3603037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2517,
          "minimum": 528.57,
          "maximum": 1842.9474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1842.9474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 1.35MM AR-5050-01",
      "code_information": [
        {
          "code": "3603040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ULTRALOOP-HS FIBER 72205445",
      "code_information": [
        {
          "code": "3603051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 862,
          "minimum": 181.02,
          "maximum": 631.1564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 631.1564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-20MM PROBE 9700-020-100",
      "code_information": [
        {
          "code": "3603057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21773,
          "minimum": 4572.33,
          "maximum": 15942.1906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15942.1906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-SPIN 17/F P01-900-1702",
      "code_information": [
        {
          "code": "3603060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1980.601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F40 64611",
      "code_information": [
        {
          "code": "3603068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63306",
      "code_information": [
        {
          "code": "3603069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.0468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-AIRFIT F30i FFM 63305",
      "code_information": [
        {
          "code": "3603070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.0468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE SMALL",
      "code_information": [
        {
          "code": "3603071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.2296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE LARGE",
      "code_information": [
        {
          "code": "3603072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.2296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-VITERA FULL FACE MEDIUM",
      "code_information": [
        {
          "code": "3603073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.2296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYNG SZ4 321400000U",
      "code_information": [
        {
          "code": "3603074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL WIDE",
      "code_information": [
        {
          "code": "3603075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.1956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-SOLO NASAL FITPACK",
      "code_information": [
        {
          "code": "3603076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 194,
          "minimum": 40.74,
          "maximum": 142.0468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.0468,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOWS-SOLO FITPACK SLP1SMSLA",
      "code_information": [
        {
          "code": "3603077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 105.4368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 9.5X400MM 1152-400",
      "code_information": [
        {
          "code": "3603081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2309,
          "minimum": 484.89,
          "maximum": 1690.6498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1690.6498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0 MCP427H",
      "code_information": [
        {
          "code": "3603082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOULTION-WOUND VASHE 118ML",
      "code_information": [
        {
          "code": "3603095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 225,
          "minimum": 47.25,
          "maximum": 164.745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ULTRABRAID SZ2 7210915",
      "code_information": [
        {
          "code": "3603096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 318,
          "minimum": 66.78,
          "maximum": 232.8396,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.8396,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-50 COBLATION 72290037",
      "code_information": [
        {
          "code": "3603101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1887,
          "minimum": 396.27,
          "maximum": 1381.6614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1381.6614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-5.5 72202530",
      "code_information": [
        {
          "code": "3603103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1097,
          "minimum": 230.37,
          "maximum": 803.2234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 803.2234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-HRVST SYS SK27",
      "code_information": [
        {
          "code": "3603104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5613,
          "minimum": 1178.73,
          "maximum": 4109.8386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4109.8386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INST-GUIDE RELEASE SN20",
      "code_information": [
        {
          "code": "3603105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-HK BONE REMOVAL SN25",
      "code_information": [
        {
          "code": "3603107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRIPLE EDGE INST SN21",
      "code_information": [
        {
          "code": "3603108",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0 C013D",
      "code_information": [
        {
          "code": "3603114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 163,
          "minimum": 34.23,
          "maximum": 119.3486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 119.3486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-FILSHIE AVM-851J",
      "code_information": [
        {
          "code": "3603115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1434,
          "minimum": 301.14,
          "maximum": 1049.9748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1049.9748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPE-CERC SUTURE AR-7267",
      "code_information": [
        {
          "code": "3603119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 14MM 2022-30-014S",
      "code_information": [
        {
          "code": "3603135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1170.0556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL MOD 16MM 2022-30-016S",
      "code_information": [
        {
          "code": "3603136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1170.0556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-PIN PROT WHT 5027-1-040",
      "code_information": [
        {
          "code": "3603139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 14FR",
      "code_information": [
        {
          "code": "3603179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3510.899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER TORQVUE 12FR",
      "code_information": [
        {
          "code": "3603180",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3510.899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 8F",
      "code_information": [
        {
          "code": "3603181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3510.899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-AMPLATZER DELIVERY 9F",
      "code_information": [
        {
          "code": "3603182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4795,
          "minimum": 1006.95,
          "maximum": 3510.899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3510.899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 8MM 022108-10",
      "code_information": [
        {
          "code": "3603183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TPR 3MM 5407-FA3-030",
      "code_information": [
        {
          "code": "3603184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1282,
          "minimum": 269.22,
          "maximum": 938.6804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 938.6804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 6MM 5820-010-160",
      "code_information": [
        {
          "code": "3603185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1093.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RASP-HELI 3.2MM 5120-080-030",
      "code_information": [
        {
          "code": "3603186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1446,
          "minimum": 303.66,
          "maximum": 1058.7612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1058.7612,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RADIUS-FULL 4.5 7205306",
      "code_information": [
        {
          "code": "3603188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 455,
          "minimum": 95.55,
          "maximum": 333.151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 333.151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0 1683H",
      "code_information": [
        {
          "code": "3603192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 74,
          "minimum": 15.54,
          "maximum": 54.1828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.1828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3603196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3050,
          "minimum": 640.5,
          "maximum": 2233.21,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2233.21,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT C0R47",
      "code_information": [
        {
          "code": "3603197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS CFF74",
      "code_information": [
        {
          "code": "3603198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEEDLE WINGED INF WNIS01",
      "code_information": [
        {
          "code": "3603199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 108,
          "minimum": 22.68,
          "maximum": 79.0776,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.0776,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED CTF73",
      "code_information": [
        {
          "code": "3603214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANN-VENOUS HI FLO 24FR 69324",
      "code_information": [
        {
          "code": "3603215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 413,
          "minimum": 86.73,
          "maximum": 302.3986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 302.3986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1A404",
      "code_information": [
        {
          "code": "3603218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 393,
          "minimum": 82.53,
          "maximum": 287.7546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 287.7546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR 72201513",
      "code_information": [
        {
          "code": "3603219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 656,
          "minimum": 137.76,
          "maximum": 480.3232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 480.3232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3603221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 615,
          "minimum": 129.15,
          "maximum": 450.303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 450.303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOVIE-E-Z CLEAN 0014A",
      "code_information": [
        {
          "code": "3603224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SOMFIT 7037-1001-00",
      "code_information": [
        {
          "code": "3603227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-MOD 12MM 2022-30-012S",
      "code_information": [
        {
          "code": "3603247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1598,
          "minimum": 335.58,
          "maximum": 1170.0556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1170.0556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROC .062 AR-8941K",
      "code_information": [
        {
          "code": "3603277",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-ZINC OXIDE REMDEY 4OZ",
      "code_information": [
        {
          "code": "3603279",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT X 2.4/45° 378824",
      "code_information": [
        {
          "code": "3603290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 308,
          "minimum": 64.68,
          "maximum": 225.5176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 225.5176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-STR SP 15° 378235",
      "code_information": [
        {
          "code": "3603291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 182,
          "minimum": 38.22,
          "maximum": 133.2604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.2604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-11G/15MM BP 0808-115-800",
      "code_information": [
        {
          "code": "3603299",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10281,
          "minimum": 2159.01,
          "maximum": 7527.7482,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7527.7482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-11G VP 0605-411-000",
      "code_information": [
        {
          "code": "3603300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2421,
          "minimum": 508.41,
          "maximum": 1772.6562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1772.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-10G VP 0605-410-000",
      "code_information": [
        {
          "code": "3603301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2421,
          "minimum": 508.41,
          "maximum": 1772.6562,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1772.6562,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G BL 3X600 AR-9091BK-30S",
      "code_information": [
        {
          "code": "3603303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL 4.2MM AR-9091-42",
      "code_information": [
        {
          "code": "3603304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2088.9666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CM VP 11G 0306-511-000",
      "code_information": [
        {
          "code": "3603319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 604,
          "minimum": 126.84,
          "maximum": 442.2488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 442.2488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5 REAMING 6143.2571",
      "code_information": [
        {
          "code": "3603340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3020,
          "minimum": 634.2,
          "maximum": 2211.244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2211.244,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4MM F/ANCHOR 72203785",
      "code_information": [
        {
          "code": "3603349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1506,
          "minimum": 316.26,
          "maximum": 1102.6932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1102.6932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X5MM 60-16005",
      "code_information": [
        {
          "code": "3603351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 940.1448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X26MM 60-16526",
      "code_information": [
        {
          "code": "3603355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1442,
          "minimum": 302.82,
          "maximum": 1055.8324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1055.8324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.6X35 92-16135",
      "code_information": [
        {
          "code": "3603356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1863,
          "minimum": 391.23,
          "maximum": 1364.0886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1364.0886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X50/5M 60-15105",
      "code_information": [
        {
          "code": "3603363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1488,
          "minimum": 312.48,
          "maximum": 1089.5136,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1089.5136,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CMF 1.5X110/20M 60-15620",
      "code_information": [
        {
          "code": "3603364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1990.1196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 VICRYL PLUS VCP762D",
      "code_information": [
        {
          "code": "3603378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 214,
          "minimum": 44.94,
          "maximum": 156.6908,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 156.6908,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13X50/13G NN-2003",
      "code_information": [
        {
          "code": "3603396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15694.707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CAL DIST 2.8MM 4040-000",
      "code_information": [
        {
          "code": "3603404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1975,
          "minimum": 414.75,
          "maximum": 1446.095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1446.095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 1.5X230MM 0109-230",
      "code_information": [
        {
          "code": "3603406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1146,
          "minimum": 240.66,
          "maximum": 839.1012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 839.1012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FREE HAND 415S002350",
      "code_information": [
        {
          "code": "3603407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1818.0526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CIRCUIT NEONATE DUAL LIMB",
      "code_information": [
        {
          "code": "3603429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 754,
          "minimum": 158.34,
          "maximum": 552.0788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 552.0788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SUCTION TABLE 8Q70R",
      "code_information": [
        {
          "code": "3603430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 633,
          "minimum": 132.93,
          "maximum": 463.4826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 463.4826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5X150 CN P41-910-5015",
      "code_information": [
        {
          "code": "3603431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1197.8792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IRRIGATION P65-001-0006-SK",
      "code_information": [
        {
          "code": "3603437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1316,
          "minimum": 276.36,
          "maximum": 963.5752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 963.5752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGHT-QUAD TIP 2762-01-0003",
      "code_information": [
        {
          "code": "3603444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3155,
          "minimum": 662.55,
          "maximum": 2310.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2310.091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2.5CM M00510880",
      "code_information": [
        {
          "code": "3603498",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1253.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHO 2CM M00510870",
      "code_information": [
        {
          "code": "3603499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1253.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GENERATOR-RF PROC RLVRFGPR",
      "code_information": [
        {
          "code": "3603504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1351.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ADD ACCESS INST RLV0075",
      "code_information": [
        {
          "code": "3603508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2891.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ACCESS INSTRUMENT RLV0045",
      "code_information": [
        {
          "code": "3603510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9838,
          "minimum": 2065.98,
          "maximum": 7203.3836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7203.3836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/10CM NN-8006",
      "code_information": [
        {
          "code": "3603527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 16702,
          "minimum": 3507.42,
          "maximum": 12229.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 12229.2044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X60/13G NN-2004",
      "code_information": [
        {
          "code": "3603530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15694.707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 40X11 SM-4011M",
      "code_information": [
        {
          "code": "3603538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ALLOGRAFT-22.5MM ABS-4057D-225",
      "code_information": [
        {
          "code": "3603542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5686,
          "minimum": 1194.06,
          "maximum": 4163.2892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4163.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL-1.5x48MM 03.130.212",
      "code_information": [
        {
          "code": "3603544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1035,
          "minimum": 217.35,
          "maximum": 757.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 3-0 VCP76",
      "code_information": [
        {
          "code": "3603545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 223,
          "minimum": 46.83,
          "maximum": 163.2806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 163.2806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "K-WIRE 9X102 HTOE 05-306",
      "code_information": [
        {
          "code": "3603547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 394,
          "minimum": 82.74,
          "maximum": 288.4868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 288.4868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-1.35X150 AR-8943-01S",
      "code_information": [
        {
          "code": "3603548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.1956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLECTOR-SPECIMEN NN-9002",
      "code_information": [
        {
          "code": "3603569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 700,
          "minimum": 147,
          "maximum": 512.54,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 512.54,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-11G/13CM NN-8007",
      "code_information": [
        {
          "code": "3603587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 18660,
          "minimum": 3918.6,
          "maximum": 13662.852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 13662.852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X95/13G NN-2006",
      "code_information": [
        {
          "code": "3603588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15694.707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-BP 13.5X75/13G NN-2005",
      "code_information": [
        {
          "code": "3603589",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 21435,
          "minimum": 4501.35,
          "maximum": 15694.707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15694.707,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-MYRID NICO NN-9001",
      "code_information": [
        {
          "code": "3603590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 113,
          "minimum": 23.73,
          "maximum": 82.7386,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7386,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 7FRX65C",
      "code_information": [
        {
          "code": "3603592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1624,
          "minimum": 341.04,
          "maximum": 1189.0928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1189.0928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 5FRX50C",
      "code_information": [
        {
          "code": "3603593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1624,
          "minimum": 341.04,
          "maximum": 1189.0928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1189.0928,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENDO BLOCK ARNDT 9FRX65C",
      "code_information": [
        {
          "code": "3603594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1882,
          "minimum": 395.22,
          "maximum": 1378.0004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1378.0004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-20-22FR/45CM G52835",
      "code_information": [
        {
          "code": "3603768",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1759,
          "minimum": 369.39,
          "maximum": 1287.9398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1287.9398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-16-18FR/45CM G52834",
      "code_information": [
        {
          "code": "3603769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1759,
          "minimum": 369.39,
          "maximum": 1287.9398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1287.9398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-32-35MM 102024003",
      "code_information": [
        {
          "code": "3603771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.4X27 ST 60-14126",
      "code_information": [
        {
          "code": "3603794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 814.2064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GOWN-WARMING BEAR PAW 81001",
      "code_information": [
        {
          "code": "3603809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 173,
          "minimum": 36.33,
          "maximum": 126.6706,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 126.6706,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-SPYSCOPE DS II M00546610",
      "code_information": [
        {
          "code": "3603810",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12212,
          "minimum": 2564.52,
          "maximum": 8941.6264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8941.6264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-EHL 1.9F 375CM M00546620",
      "code_information": [
        {
          "code": "3603814",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2879,
          "minimum": 604.59,
          "maximum": 2108.0038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2108.0038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONEMILL MD 5420-MED-000",
      "code_information": [
        {
          "code": "3603815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3354,
          "minimum": 704.34,
          "maximum": 2455.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2455.7988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CRV DIAMOND 15° 1600650",
      "code_information": [
        {
          "code": "3603818",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-CYLINDER 60° 1600578",
      "code_information": [
        {
          "code": "3603819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST 1.9X27MM 60-19126",
      "code_information": [
        {
          "code": "3603820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1112,
          "minimum": 233.52,
          "maximum": 814.2064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 814.2064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6X200MM P99-192-1620",
      "code_information": [
        {
          "code": "3603836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1003,
          "minimum": 210.63,
          "maximum": 734.3966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 734.3966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2.0 3846T",
      "code_information": [
        {
          "code": "3603837",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8.7864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y415H",
      "code_information": [
        {
          "code": "3603838",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12,
          "minimum": 2.52,
          "maximum": 8.7864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8.7864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS II 7-0 Z135H",
      "code_information": [
        {
          "code": "3603876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 273,
          "minimum": 57.33,
          "maximum": 199.8906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 199.8906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-OS AG 45X6 SM-4506",
      "code_information": [
        {
          "code": "3603888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-38MM ARS743201",
      "code_information": [
        {
          "code": "3603895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1150.2862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-14X127MM ARS743303",
      "code_information": [
        {
          "code": "3603897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1150.2862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE .9MM 57S90005",
      "code_information": [
        {
          "code": "3603901",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 472.269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ANTI SKIVE 1.4MM 57S90004",
      "code_information": [
        {
          "code": "3603902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 472.269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM MXM-072-19",
      "code_information": [
        {
          "code": "3603904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1799,
          "minimum": 377.79,
          "maximum": 1317.2278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1317.2278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OSTEOTOME-76/3 ARS743202",
      "code_information": [
        {
          "code": "3603910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1571,
          "minimum": 329.91,
          "maximum": 1150.2862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1150.2862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 8.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603923",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 7.0MM W/ SUCT",
      "code_information": [
        {
          "code": "3603924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SUBGLOTTIC 6.5MM W/ SUCT",
      "code_information": [
        {
          "code": "3603925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SM CHLD NR34015813",
      "code_information": [
        {
          "code": "3603926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.1658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015814",
      "code_information": [
        {
          "code": "3603927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 89,
          "minimum": 18.69,
          "maximum": 65.1658,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.1658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-PRO-FLOW NR37000145",
      "code_information": [
        {
          "code": "3603928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SPO2 ADULT NR37004030",
      "code_information": [
        {
          "code": "3603929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 81,
          "minimum": 17.01,
          "maximum": 59.3082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.3082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMETRY EM951160CP",
      "code_information": [
        {
          "code": "3603931",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 204,
          "minimum": 42.84,
          "maximum": 149.3688,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 149.3688,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-ADULT NR34015818",
      "code_information": [
        {
          "code": "3603932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASALNR354S5011",
      "code_information": [
        {
          "code": "3603933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.1998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CHILD 7FT NR34015816",
      "code_information": [
        {
          "code": "3603934",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG WEBB NR104B1420",
      "code_information": [
        {
          "code": "3603935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 95.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASTE-EEG 8OZ NR10200005",
      "code_information": [
        {
          "code": "3603936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 529,
          "minimum": 111.09,
          "maximum": 387.3338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 387.3338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUPREP-4OZ TUBE NR10210004",
      "code_information": [
        {
          "code": "3603937",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 158,
          "minimum": 33.18,
          "maximum": 115.6876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 115.6876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-THERMOCAN NR34015808",
      "code_information": [
        {
          "code": "3603938",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 59,
          "minimum": 12.39,
          "maximum": 43.1998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.1998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENT 20FR/6.7MM 80220",
      "code_information": [
        {
          "code": "3603955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 387,
          "minimum": 81.27,
          "maximum": 283.3614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 283.3614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-CLEARVUE LARYNG #3",
      "code_information": [
        {
          "code": "3603957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 203,
          "minimum": 42.63,
          "maximum": 148.6366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 148.6366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NOMOLINE LH NASAL/ORAL",
      "code_information": [
        {
          "code": "3603958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 208,
          "minimum": 43.68,
          "maximum": 152.2976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 152.2976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 22FR BE2050",
      "code_information": [
        {
          "code": "3603960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 872.0502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-PUNCTURE 18FR BE6050",
      "code_information": [
        {
          "code": "3603961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1191,
          "minimum": 250.11,
          "maximum": 872.0502,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 872.0502,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LITHOTRIPER PROBE 3.9MM",
      "code_information": [
        {
          "code": "3603972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4400,
          "minimum": 924,
          "maximum": 3221.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3221.68,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRIVER-T-15 TORQUE 702750",
      "code_information": [
        {
          "code": "3603979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3611,
          "minimum": 758.31,
          "maximum": 2643.9742,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2643.9742,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIMITER-TORQUE 2.5NM 702760",
      "code_information": [
        {
          "code": "3603985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4015,
          "minimum": 843.15,
          "maximum": 2939.783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2939.783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/15 STPL THN00482",
      "code_information": [
        {
          "code": "3603988",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2099,
          "minimum": 440.79,
          "maximum": 1536.8878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1536.8878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-PK 2.8/20 STPL THN00483",
      "code_information": [
        {
          "code": "3603989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2099,
          "minimum": 440.79,
          "maximum": 1536.8878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1536.8878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLANGE-PROVOX XTRA 22.5FR 7275",
      "code_information": [
        {
          "code": "3604022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM*CLEARIFY 21-345",
      "code_information": [
        {
          "code": "3604025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-5-0 CHROMIC GUT 792G",
      "code_information": [
        {
          "code": "3604027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 250,
          "minimum": 52.5,
          "maximum": 183.05,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 183.05,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-NANO 29.5X7MM SM-3115",
      "code_information": [
        {
          "code": "3604043",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-MET 20MM MPN20120",
      "code_information": [
        {
          "code": "3604048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-PHAL 20MM MPN20020",
      "code_information": [
        {
          "code": "3604049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM SHT MSTD1030",
      "code_information": [
        {
          "code": "3604050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-CIRCUMCISION 1.45CM",
      "code_information": [
        {
          "code": "3604060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 605,
          "minimum": 127.05,
          "maximum": 442.981,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 442.981,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE DUAL 844023S",
      "code_information": [
        {
          "code": "3604137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 291,
          "minimum": 61.11,
          "maximum": 213.0702,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 213.0702,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-OPTIVANTAGE SINGLE 800099S",
      "code_information": [
        {
          "code": "3604138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 93.7216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G NT 2X200 MSG20200",
      "code_information": [
        {
          "code": "3604156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 716,
          "minimum": 150.36,
          "maximum": 524.2552,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.2552,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 3.6 F/5.5MM MSN10013",
      "code_information": [
        {
          "code": "3604157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2718,
          "minimum": 570.78,
          "maximum": 1990.1196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1990.1196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-STAPLE 3MM LNG MSTD0030",
      "code_information": [
        {
          "code": "3604158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1201,
          "minimum": 252.21,
          "maximum": 879.3722,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 879.3722,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PUMA-G GENERATION 2",
      "code_information": [
        {
          "code": "3604162",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10740,
          "minimum": 2255.4,
          "maximum": 7863.828,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7863.828,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-STAPLE SZ THN00292",
      "code_information": [
        {
          "code": "3604165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2014,
          "minimum": 422.94,
          "maximum": 1474.6508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1474.6508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CN 5.0MM 3100-01-0005",
      "code_information": [
        {
          "code": "3604167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.9954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 2.4MM 2900-04-0229",
      "code_information": [
        {
          "code": "3604168",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1431,
          "minimum": 300.51,
          "maximum": 1047.7782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1047.7782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER-6.5MM 3100-01-0007",
      "code_information": [
        {
          "code": "3604169",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3357,
          "minimum": 704.97,
          "maximum": 2457.9954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2457.9954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NAIL-7X90 3200-01-7090",
      "code_information": [
        {
          "code": "3604170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 15795,
          "minimum": 3316.95,
          "maximum": 11565.099,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 11565.099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-SONATA DE-001-10",
      "code_information": [
        {
          "code": "3604172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 877,
          "minimum": 184.17,
          "maximum": 642.1394,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 642.1394,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IVAS BONE BX 0306-115-000",
      "code_information": [
        {
          "code": "3604196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 798,
          "minimum": 167.58,
          "maximum": 584.2956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 584.2956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-DSG XS 2.5MM P1-AU514",
      "code_information": [
        {
          "code": "3604197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7870,
          "minimum": 1652.7,
          "maximum": 5762.414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5762.414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DISTRACTOR 12MM 02.600.022",
      "code_information": [
        {
          "code": "3604198",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 726.3424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-#0/8\\\"\\\" GREEN VLOCA008L",
      "code_information": [
        {
          "code": "3604209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1317,
          "minimum": 276.57,
          "maximum": 964.3074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 964.3074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VICRYL VCP104G",
      "code_information": [
        {
          "code": "3604215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 160,
          "minimum": 33.6,
          "maximum": 117.152,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 117.152,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0 MX977",
      "code_information": [
        {
          "code": "3604217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 320,
          "minimum": 67.2,
          "maximum": 234.304,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 234.304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MINITAPE-LOOPED 72205435",
      "code_information": [
        {
          "code": "3604218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 913,
          "minimum": 191.73,
          "maximum": 668.4986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 668.4986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATE STD 20MM M0056183",
      "code_information": [
        {
          "code": "3604224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 297,
          "minimum": 62.37,
          "maximum": 217.4634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 217.4634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ACESSA 7300",
      "code_information": [
        {
          "code": "3604227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 14892,
          "minimum": 3127.32,
          "maximum": 10903.9224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 10903.9224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-HEAD SILVERMAN SZ F",
      "code_information": [
        {
          "code": "3604228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 2X12MM AR-300-B003",
      "code_information": [
        {
          "code": "3604244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1806.3374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STR 3.1X20MM AR-300-B202",
      "code_information": [
        {
          "code": "3604247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2467,
          "minimum": 518.07,
          "maximum": 1806.3374,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1806.3374,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUT 2 P41-960-0020",
      "code_information": [
        {
          "code": "3604263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1723,
          "minimum": 361.83,
          "maximum": 1261.5806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1261.5806,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-5.5X150 CN P41-910-5515",
      "code_information": [
        {
          "code": "3604264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1197.8792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4X150 CN P41-910-4015",
      "code_information": [
        {
          "code": "3604265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1197.8792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPIKE-GPS LONG 6143.2515",
      "code_information": [
        {
          "code": "3604278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6702,
          "minimum": 1407.42,
          "maximum": 4907.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4907.2044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 8.0",
      "code_information": [
        {
          "code": "3604284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED 7.5",
      "code_information": [
        {
          "code": "3604285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO CUFFED",
      "code_information": [
        {
          "code": "3604286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-INNER TRACH PORTEX 100",
      "code_information": [
        {
          "code": "3604287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 58,
          "minimum": 12.18,
          "maximum": 42.4676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEMALE TO FEMALE",
      "code_information": [
        {
          "code": "3604289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-1.8MM PERK AR-3610PK-3",
      "code_information": [
        {
          "code": "3604294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1586,
          "minimum": 333.06,
          "maximum": 1161.2692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1161.2692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 6X7 AR-6535TD",
      "code_information": [
        {
          "code": "3604297",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 293.6122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SR8 GEMINI AR-6572",
      "code_information": [
        {
          "code": "3604301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 293.6122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLSRE SKN 22CM EF70401",
      "code_information": [
        {
          "code": "3604305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 711,
          "minimum": 149.31,
          "maximum": 520.5942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 520.5942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON-SH 14 1/4\\\" 020116801",
      "code_information": [
        {
          "code": "3604307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1305,
          "minimum": 274.05,
          "maximum": 955.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 955.521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.7/F 2.4 AR-8916-18",
      "code_information": [
        {
          "code": "3604317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 537,
          "minimum": 112.77,
          "maximum": 393.1914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.1914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-WIRE FIX XL 76-10104",
      "code_information": [
        {
          "code": "3604319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1375,
          "minimum": 288.75,
          "maximum": 1006.775,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1006.775,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR PEDIATRIC S-1003",
      "code_information": [
        {
          "code": "3604329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 264,
          "minimum": 55.44,
          "maximum": 193.3008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 193.3008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROCKER-FOOT SHORT 71-6130S",
      "code_information": [
        {
          "code": "3604330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 10354,
          "minimum": 2174.34,
          "maximum": 7581.1988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7581.1988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 4H 76-10140",
      "code_information": [
        {
          "code": "3604333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1238.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 2H 76-10125",
      "code_information": [
        {
          "code": "3604334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1238.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 200MM 76-11200",
      "code_information": [
        {
          "code": "3604335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1151,
          "minimum": 241.71,
          "maximum": 842.7622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 842.7622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-THRD 115MM 76-11115",
      "code_information": [
        {
          "code": "3604337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 934,
          "minimum": 196.14,
          "maximum": 683.8748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 683.8748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-FH 4.2MM AR-9091F-42",
      "code_information": [
        {
          "code": "3604351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2853,
          "minimum": 599.13,
          "maximum": 2088.9666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2088.9666,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-CON 4.3X13MM AR-300-B101",
      "code_information": [
        {
          "code": "3604352",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2470,
          "minimum": 518.7,
          "maximum": 1808.534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1808.534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE SKIN EF70466",
      "code_information": [
        {
          "code": "3604355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 933,
          "minimum": 195.93,
          "maximum": 683.1426,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 683.1426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ACTIVALVE-PROVOX STRONG 7161",
      "code_information": [
        {
          "code": "3604357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2891.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET ACCESS INST LV3 RLV0055",
      "code_information": [
        {
          "code": "3604369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 12997,
          "minimum": 2729.37,
          "maximum": 9516.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 9516.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE K 1.6X200 AR-5050K-1",
      "code_information": [
        {
          "code": "3604376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 478,
          "minimum": 100.38,
          "maximum": 349.9916,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.9916,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REAMER 9MM C P01-901-0901-S",
      "code_information": [
        {
          "code": "3604385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2705,
          "minimum": 568.05,
          "maximum": 1980.601,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1980.601,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET SCREW T7 5560010000",
      "code_information": [
        {
          "code": "3604395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 646.5326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-FOGARTY DSOFT33",
      "code_information": [
        {
          "code": "3604398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 361,
          "minimum": 75.81,
          "maximum": 264.3242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 264.3242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-DRAIN/FLUSH LL AFA-LL",
      "code_information": [
        {
          "code": "3604403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 224,
          "minimum": 47.04,
          "maximum": 164.0128,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0128,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #4",
      "code_information": [
        {
          "code": "3604406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 297.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-LARYN #3",
      "code_information": [
        {
          "code": "3604407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 406,
          "minimum": 85.26,
          "maximum": 297.2732,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 297.2732,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-6 THD/10 HEX 76-10180",
      "code_information": [
        {
          "code": "3604415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 235,
          "minimum": 49.35,
          "maximum": 172.067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 172.067,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NUT-FLANGE 10HX 76-10182",
      "code_information": [
        {
          "code": "3604416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 315,
          "minimum": 66.15,
          "maximum": 230.643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 230.643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD +3OS/25MM MWJ007",
      "code_information": [
        {
          "code": "3604423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5858,
          "minimum": 1230.18,
          "maximum": 4289.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4289.2276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODEL-REV BONE MWJ015",
      "code_information": [
        {
          "code": "3604424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-3.0 A-3938",
      "code_information": [
        {
          "code": "3604432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2061,
          "minimum": 432.81,
          "maximum": 1509.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1509.0642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 16FR 26-016",
      "code_information": [
        {
          "code": "3604433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 666.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 12FR 26-012",
      "code_information": [
        {
          "code": "3604434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 666.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CORGRIP 18FR 26-018",
      "code_information": [
        {
          "code": "3604435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 910,
          "minimum": 191.1,
          "maximum": 666.302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 666.302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-NYLON 11MM/265ML CD005",
      "code_information": [
        {
          "code": "3604438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 657,
          "minimum": 137.97,
          "maximum": 481.0554,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 481.0554,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-6X150 CN P41-910-6015",
      "code_information": [
        {
          "code": "3604457",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1636,
          "minimum": 343.56,
          "maximum": 1197.8792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1197.8792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO CAL 5.5MM S0288-200",
      "code_information": [
        {
          "code": "3604470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2470,
          "minimum": 518.7,
          "maximum": 1808.534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1808.534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-G 1.6MM TRC AR-18700-71",
      "code_information": [
        {
          "code": "3604479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 299,
          "minimum": 62.79,
          "maximum": 218.9278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.9278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-AEROGEN SOLO",
      "code_information": [
        {
          "code": "3604489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 686,
          "minimum": 144.06,
          "maximum": 502.2892,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 502.2892,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP NIV 73-1069210",
      "code_information": [
        {
          "code": "3604490",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 128,
          "minimum": 26.88,
          "maximum": 93.7216,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 93.7216,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-HO 7/1.6X80 P99-205-1608",
      "code_information": [
        {
          "code": "3604512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1065,
          "minimum": 223.65,
          "maximum": 779.793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 779.793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GRAFT SIZING AR-1676ST",
      "code_information": [
        {
          "code": "3604518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2079,
          "minimum": 436.59,
          "maximum": 1522.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-STEINMANN .157X9\\\"\\\" KI71615",
      "code_information": [
        {
          "code": "3604550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 197,
          "minimum": 41.37,
          "maximum": 144.2434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 144.2434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL SP-78105",
      "code_information": [
        {
          "code": "3604567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 932.8228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 1MM 5820-013-010",
      "code_information": [
        {
          "code": "3604568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 935.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 12X18/2 DS24",
      "code_information": [
        {
          "code": "3604569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 769,
          "minimum": 161.49,
          "maximum": 563.0618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 563.0618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/0 DS26",
      "code_information": [
        {
          "code": "3604570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 832,
          "minimum": 174.72,
          "maximum": 609.1904,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 609.1904,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-DENTAL 50X18/2 DS28",
      "code_information": [
        {
          "code": "3604571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 815,
          "minimum": 171.15,
          "maximum": 596.743,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 596.743,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS 29/37 TF2937O",
      "code_information": [
        {
          "code": "3604581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 610,
          "minimum": 128.1,
          "maximum": 446.642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 446.642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-AMPLATZ 8F M0062601010",
      "code_information": [
        {
          "code": "3604584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 481,
          "minimum": 101.01,
          "maximum": 352.1882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 352.1882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-33MM LF EVERGRIP33",
      "code_information": [
        {
          "code": "3604594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 359,
          "minimum": 75.39,
          "maximum": 262.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.8598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEM 19F/6.3 96570-119",
      "code_information": [
        {
          "code": "3604596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2245,
          "minimum": 471.45,
          "maximum": 1643.789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1643.789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 19F/6.3MM 96530-119",
      "code_information": [
        {
          "code": "3604597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1818.0526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEM CN 21F/7MM 96530-121",
      "code_information": [
        {
          "code": "3604598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2483,
          "minimum": 521.43,
          "maximum": 1818.0526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1818.0526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WHITE 15X12MM DLP-W11",
      "code_information": [
        {
          "code": "3604599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 176.4602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-YELLOW 15X12MM DLP-S11",
      "code_information": [
        {
          "code": "3604600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 176.4602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-11MM 261222",
      "code_information": [
        {
          "code": "3604605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1960.8316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 650-750CC SZHP68650",
      "code_information": [
        {
          "code": "3604611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 550-640CC SZHP68550",
      "code_information": [
        {
          "code": "3604612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 425-455CC SZHP68425",
      "code_information": [
        {
          "code": "3604613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 430,
          "minimum": 90.3,
          "maximum": 314.846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 314.846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 320-340CC SZHP68320",
      "code_information": [
        {
          "code": "3604614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 549,
          "minimum": 115.29,
          "maximum": 401.9778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 401.9778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 200-260CC SZHP68200",
      "code_information": [
        {
          "code": "3604615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-HP 750-800CC SZHP68750",
      "code_information": [
        {
          "code": "3604616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-4x30/10 PAL-402LL",
      "code_information": [
        {
          "code": "3604618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 796,
          "minimum": 167.16,
          "maximum": 582.8312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 582.8312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 2MM 5820-010-120",
      "code_information": [
        {
          "code": "3604621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 3MM 5820-010-130",
      "code_information": [
        {
          "code": "3604622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-RND FLUTE 4MM 5820-010-140",
      "code_information": [
        {
          "code": "3604623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 3MM 5820-012-030",
      "code_information": [
        {
          "code": "3604624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1277,
          "minimum": 268.17,
          "maximum": 935.0194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 935.0194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND 4MM 5820-012-040",
      "code_information": [
        {
          "code": "3604625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1093.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 3 5820-013-030",
      "code_information": [
        {
          "code": "3604626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIA RND/CRS 4 5820-013-040",
      "code_information": [
        {
          "code": "3604627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1365,
          "minimum": 286.65,
          "maximum": 999.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 999.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHEST SAHARA S-1150-08LF",
      "code_information": [
        {
          "code": "3604628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1182,
          "minimum": 248.22,
          "maximum": 865.4604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 865.4604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-NASOPHARYN 20FR 123120",
      "code_information": [
        {
          "code": "3604629",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 68,
          "minimum": 14.28,
          "maximum": 49.7896,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.7896,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12X150MM FE CFF71",
      "code_information": [
        {
          "code": "3604631",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 321,
          "minimum": 67.41,
          "maximum": 235.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.0362,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X150MM FE CFF01",
      "code_information": [
        {
          "code": "3604632",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5X100MM BLADE CFB03",
      "code_information": [
        {
          "code": "3604633",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 269,
          "minimum": 56.49,
          "maximum": 196.9618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.9618,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 9MM 022109-10",
      "code_information": [
        {
          "code": "3604634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 10MM 022110-10",
      "code_information": [
        {
          "code": "3604635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 12MM 022112-10",
      "code_information": [
        {
          "code": "3604636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 93,
          "minimum": 19.53,
          "maximum": 68.0946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.0946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 14MM 022114-10",
      "code_information": [
        {
          "code": "3604637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 97,
          "minimum": 20.37,
          "maximum": 71.0234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.0234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CVD 16MM 022116-10",
      "code_information": [
        {
          "code": "3604638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 106,
          "minimum": 22.26,
          "maximum": 77.6132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC 3-0 VLOCM0644",
      "code_information": [
        {
          "code": "3604653",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 541,
          "minimum": 113.61,
          "maximum": 396.1202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 396.1202,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO BULL M0068332451",
      "code_information": [
        {
          "code": "3604654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 390.2626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CAPIO 0 M0068331371",
      "code_information": [
        {
          "code": "3604655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 533,
          "minimum": 111.93,
          "maximum": 390.2626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 390.2626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-JP SUCT 10MM SU130-1311",
      "code_information": [
        {
          "code": "3604656",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WOUND DRAIN 10F SU130-402D",
      "code_information": [
        {
          "code": "3604657",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 127,
          "minimum": 26.67,
          "maximum": 92.9894,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 92.9894,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MUSCLE-TRAINING DEVICE",
      "code_information": [
        {
          "code": "3604659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 330,
          "minimum": 69.3,
          "maximum": 241.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 241.626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ACORN 5MM 5820-030-550",
      "code_information": [
        {
          "code": "3604667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1494,
          "minimum": 313.74,
          "maximum": 1093.9068,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1093.9068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERY 2X14MM 31200",
      "code_information": [
        {
          "code": "3604670",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 646.5326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-ARTERY 1.5X14MM 31150",
      "code_information": [
        {
          "code": "3604671",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 883,
          "minimum": 185.43,
          "maximum": 646.5326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 646.5326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-ACCES 8MM IAS8-120LP",
      "code_information": [
        {
          "code": "3604725",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 942,
          "minimum": 197.82,
          "maximum": 689.7324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 689.7324,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR 29MM ECS29B",
      "code_information": [
        {
          "code": "3604726",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2143,
          "minimum": 450.03,
          "maximum": 1569.1046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1569.1046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOULDER LG/18-19.5\\\"\\\"",
      "code_information": [
        {
          "code": "3604728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 472.269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SHOULDER M/16.5-18\\\"\\\"",
      "code_information": [
        {
          "code": "3604729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 472.269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-SURGICAL 4MM 080-403",
      "code_information": [
        {
          "code": "3604730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 254,
          "minimum": 53.34,
          "maximum": 185.9788,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.9788,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LARGE COMBO AR-8964-07",
      "code_information": [
        {
          "code": "3604737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1732.2,
          "minimum": 363.762,
          "maximum": 1268.3168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1268.3168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN LG AR-8964-08",
      "code_information": [
        {
          "code": "3604738",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1396.5,
          "minimum": 293.265,
          "maximum": 1022.5173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1022.5173,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ATTACH-ROD LG CLMP AR-8964-09",
      "code_information": [
        {
          "code": "3604739",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1309,
          "minimum": 274.89,
          "maximum": 958.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 958.4498,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 100 AR-8964R-100",
      "code_information": [
        {
          "code": "3604740",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591.5,
          "minimum": 124.215,
          "maximum": 433.0963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 433.0963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 250 AR-8964R-250",
      "code_information": [
        {
          "code": "3604741",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591.5,
          "minimum": 124.215,
          "maximum": 433.0963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 433.0963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CARBON 300 AR-8964R-300",
      "code_information": [
        {
          "code": "3604742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 665,
          "minimum": 139.65,
          "maximum": 486.913,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 486.913,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 3.5X195MM AR-8964-10",
      "code_information": [
        {
          "code": "3604743",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 332.5,
          "minimum": 69.825,
          "maximum": 243.4565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 243.4565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-END CAP AR-8964-22",
      "code_information": [
        {
          "code": "3604744",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 175,
          "minimum": 36.75,
          "maximum": 128.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 128.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-REMV FIBULOCK AR-8973RK",
      "code_information": [
        {
          "code": "3604749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6093,
          "minimum": 1279.53,
          "maximum": 4461.2946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4461.2946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.5MM AR-8973-25",
      "code_information": [
        {
          "code": "3604769",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1042,
          "minimum": 218.82,
          "maximum": 762.9524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 762.9524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-LARGE COMBO AR-8964-07",
      "code_information": [
        {
          "code": "3604775",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3322,
          "minimum": 697.62,
          "maximum": 2432.3684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2432.3684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN LG AR-8964-08",
      "code_information": [
        {
          "code": "3604776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2678,
          "minimum": 562.38,
          "maximum": 1960.8316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1960.8316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ATTACH-ROD LG CLMP AR-8964-09",
      "code_information": [
        {
          "code": "3604777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2510,
          "minimum": 527.1,
          "maximum": 1837.822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1837.822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-QC 3.5X195MM AR-8964-10",
      "code_information": [
        {
          "code": "3604781",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 992,
          "minimum": 208.32,
          "maximum": 726.3424,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 726.3424,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-END CAP AR-8964-22",
      "code_information": [
        {
          "code": "3604782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-GLD CTR/25MM MWJ005",
      "code_information": [
        {
          "code": "3604783",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5858,
          "minimum": 1230.18,
          "maximum": 4289.2276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4289.2276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3X215MM 542053",
      "code_information": [
        {
          "code": "3604785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1886,
          "minimum": 396.06,
          "maximum": 1380.9292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1380.9292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X215MM 542051",
      "code_information": [
        {
          "code": "3604786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1776,
          "minimum": 372.96,
          "maximum": 1300.3872,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1300.3872,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CPM-SOFT GOODS",
      "code_information": [
        {
          "code": "3604787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 325,
          "minimum": 68.25,
          "maximum": 237.965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBGAUZE*SURGITUBE SZ 5/8\\\"",
      "code_information": [
        {
          "code": "3604794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 142,
          "minimum": 29.82,
          "maximum": 103.9724,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.9724,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATOR XS 11MM 10/BX",
      "code_information": [
        {
          "code": "3604795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 592,
          "minimum": 124.32,
          "maximum": 433.4624,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 433.4624,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR Y 1/4x1/4x1/4",
      "code_information": [
        {
          "code": "3604798",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 131,
          "minimum": 27.51,
          "maximum": 95.9182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 95.9182,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-NANO HF 125 AR-3210-0052",
      "code_information": [
        {
          "code": "3604799",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 696.5,
          "minimum": 146.265,
          "maximum": 509.9773,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 509.9773,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 2.5X215MM 542021",
      "code_information": [
        {
          "code": "3604823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1885,
          "minimum": 395.85,
          "maximum": 1380.197,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1380.197,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT AO 93MM 542031",
      "code_information": [
        {
          "code": "3604824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3667,
          "minimum": 770.07,
          "maximum": 2684.9774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2684.9774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT AO 180MM 542032",
      "code_information": [
        {
          "code": "3604825",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3949,
          "minimum": 829.29,
          "maximum": 2891.4578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2891.4578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT DRILL 3.5X135MM 542022",
      "code_information": [
        {
          "code": "3604832",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1664,
          "minimum": 349.44,
          "maximum": 1218.3808,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1218.3808,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-AO 4X165 AR-9095-43S",
      "code_information": [
        {
          "code": "3604868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1941,
          "minimum": 407.61,
          "maximum": 1421.2002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1421.2002,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-SX DRY 13CM PSS13DF-5",
      "code_information": [
        {
          "code": "3604876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1671,
          "minimum": 350.91,
          "maximum": 1223.5062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1223.5062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESTRAINT-HEAD T-MAX 7210559",
      "code_information": [
        {
          "code": "3604877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 293.6122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2X135MM 542000",
      "code_information": [
        {
          "code": "3604891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1626,
          "minimum": 341.46,
          "maximum": 1190.5572,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1190.5572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIPULATOR-UTER 60-6085-201A",
      "code_information": [
        {
          "code": "3604912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 622.37,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-SHOULDER XL/19.5-22\\\"\\\"",
      "code_information": [
        {
          "code": "3604916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 645,
          "minimum": 135.45,
          "maximum": 472.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 472.269,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH 6MM NIM 8229706",
      "code_information": [
        {
          "code": "3604917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2020.1398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH 8MM NIM 8229708",
      "code_information": [
        {
          "code": "3604918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2759,
          "minimum": 579.39,
          "maximum": 2020.1398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2020.1398,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-LEAD 518-024",
      "code_information": [
        {
          "code": "3604919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1149,
          "minimum": 241.29,
          "maximum": 841.2978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.2978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-BULLDOG LEAD LR-LED01",
      "code_information": [
        {
          "code": "3604933",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2457,
          "minimum": 515.97,
          "maximum": 1799.0154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1799.0154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TD 7X7 AR-6570TD",
      "code_information": [
        {
          "code": "3604936",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 401,
          "minimum": 84.21,
          "maximum": 293.6122,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 293.6122,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7X125MM 542002",
      "code_information": [
        {
          "code": "3604942",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1702,
          "minimum": 357.42,
          "maximum": 1246.2044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1246.2044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-NEURO PDCMF-BP-001",
      "code_information": [
        {
          "code": "3604949",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1846,
          "minimum": 387.66,
          "maximum": 1351.6412,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1351.6412,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELEASE-TRITOME 3WAY SN31",
      "code_information": [
        {
          "code": "3604952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2651,
          "minimum": 556.71,
          "maximum": 1941.0622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1941.0622,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-NEXUS CONNECTORS BP6866N",
      "code_information": [
        {
          "code": "3604957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 140.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-LEG SM/16-20\\\"\\\" LS101",
      "code_information": [
        {
          "code": "3604958",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 591,
          "minimum": 124.11,
          "maximum": 432.7302,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 432.7302,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL PLUS 5-0 VCP834G",
      "code_information": [
        {
          "code": "3604959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 82,
          "minimum": 17.22,
          "maximum": 60.0404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.0404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-SINSKEY 45 /10MM 581442",
      "code_information": [
        {
          "code": "3604965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 371,
          "minimum": 77.91,
          "maximum": 271.6462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 271.6462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-AGILIS HISPRO DS3A001",
      "code_information": [
        {
          "code": "3604978",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 418,
          "minimum": 87.78,
          "maximum": 306.0596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.0596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-LONG INSERTION 40555",
      "code_information": [
        {
          "code": "3604987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3349,
          "minimum": 703.29,
          "maximum": 2452.1378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2452.1378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY VIAL HH9006",
      "code_information": [
        {
          "code": "3604989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3536,
          "minimum": 742.56,
          "maximum": 2589.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2589.0592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DRL 4MM CLOSED AR-1595TC",
      "code_information": [
        {
          "code": "3605014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1371,
          "minimum": 287.91,
          "maximum": 1003.8462,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1003.8462,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-4.5X250 SQC 76-10047",
      "code_information": [
        {
          "code": "3605028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2009,
          "minimum": 421.89,
          "maximum": 1470.9898,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1470.9898,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM CENTERING 76-10210",
      "code_information": [
        {
          "code": "3605029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 934,
          "minimum": 196.14,
          "maximum": 683.8748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 683.8748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-THRD 5H 76-10145",
      "code_information": [
        {
          "code": "3605031",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1238.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOLT-6X8MM RANCHO 76-10165",
      "code_information": [
        {
          "code": "3605032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 376,
          "minimum": 78.96,
          "maximum": 275.3072,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 275.3072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-180MM BUTT 71-61180",
      "code_information": [
        {
          "code": "3605034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1238.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-150MM BUTT 71-61150",
      "code_information": [
        {
          "code": "3605035",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1692,
          "minimum": 355.32,
          "maximum": 1238.8824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1238.8824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARCH-FOOT 150MM 71-90150",
      "code_information": [
        {
          "code": "3605036",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5854,
          "minimum": 1229.34,
          "maximum": 4286.2988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4286.2988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FOOT 150MM LONG 71-6100L",
      "code_information": [
        {
          "code": "3605037",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 9905,
          "minimum": 2080.05,
          "maximum": 7252.441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7252.441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-FULL 155MM 71-10155",
      "code_information": [
        {
          "code": "3605038",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6752,
          "minimum": 1417.92,
          "maximum": 4943.8144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4943.8144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-2-0 ETHIBOND 10X86N",
      "code_information": [
        {
          "code": "3605039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 484,
          "minimum": 101.64,
          "maximum": 354.3848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 354.3848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOTTLE-STONE COLLECT XUSM0031",
      "code_information": [
        {
          "code": "3605040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 503,
          "minimum": 105.63,
          "maximum": 368.2966,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 368.2966,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-AP LNG/LT AR-8954-10",
      "code_information": [
        {
          "code": "3605076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3379,
          "minimum": 709.59,
          "maximum": 2474.1038,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2474.1038,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-GIGLI SAW 260-104",
      "code_information": [
        {
          "code": "3605086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IMPELLA AXILLARY 0052-0011",
      "code_information": [
        {
          "code": "3605088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURESTEP MALE EXT CATH",
      "code_information": [
        {
          "code": "3605089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURESTEP MALE EXT CATH",
      "code_information": [
        {
          "code": "3605090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 72,
          "minimum": 15.12,
          "maximum": 52.7184,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.7184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IV 22G X 2.5\\\" 4251622-02",
      "code_information": [
        {
          "code": "3605091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 134,
          "minimum": 28.14,
          "maximum": 98.1148,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.1148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-TPR 3.2/3.9X450 1420-0065S",
      "code_information": [
        {
          "code": "3605102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1274,
          "minimum": 267.54,
          "maximum": 932.8228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 932.8228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-STERNAL #6 14\\\" 040-365",
      "code_information": [
        {
          "code": "3605111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1245,
          "minimum": 261.45,
          "maximum": 911.589,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 911.589,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EXT 1.2 MICRON FILTER",
      "code_information": [
        {
          "code": "3605116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 69,
          "minimum": 14.49,
          "maximum": 50.5218,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.5218,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO ST 90 AR-4068-90",
      "code_information": [
        {
          "code": "3605127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1535,
          "minimum": 322.35,
          "maximum": 1123.927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1123.927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCOPE-BRONCH DISP EXT 6.2/3.2",
      "code_information": [
        {
          "code": "3605137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1980,
          "minimum": 415.8,
          "maximum": 1449.756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1449.756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STEM-HIP S5/38.5X105 7000-6605",
      "code_information": [
        {
          "code": "3699561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 7456,
          "minimum": 1565.76,
          "maximum": 5459.2832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 5459.2832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-JEWETT TLSO S/M REGULAR",
      "code_information": [
        {
          "code": "3699634",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1362,
          "minimum": 286.02,
          "maximum": 997.2564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 997.2564,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 15M",
      "code_information": [
        {
          "code": "3700007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3512,
          "minimum": 737.52,
          "maximum": 2571.4864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2571.4864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-CHLORPREP    260700",
      "code_information": [
        {
          "code": "3800580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 54,
          "minimum": 11.34,
          "maximum": 39.5388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 39.5388,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TORQUE-DEVICE           46-550",
      "code_information": [
        {
          "code": "3801395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSEMBLY-18G BARE NEEDLE 78060",
      "code_information": [
        {
          "code": "3820010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1115,
          "minimum": 234.15,
          "maximum": 816.403,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 816.403,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 18X6     618735",
      "code_information": [
        {
          "code": "3820055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2797,
          "minimum": 587.37,
          "maximum": 2047.9634,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2047.9634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 22X6     618743",
      "code_information": [
        {
          "code": "3820057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2799,
          "minimum": 587.79,
          "maximum": 2049.4278,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2049.4278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-PTV Z-MED 25x6 611771",
      "code_information": [
        {
          "code": "3820062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3718,
          "minimum": 780.78,
          "maximum": 2722.3196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2722.3196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BACKSTOP                MBS100",
      "code_information": [
        {
          "code": "3820086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 94,
          "minimum": 19.74,
          "maximum": 68.8268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.8268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-SURGICAL PACEDISP 5833SL",
      "code_information": [
        {
          "code": "3820163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 357,
          "minimum": 74.97,
          "maximum": 261.3954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 261.3954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING DISP         6651",
      "code_information": [
        {
          "code": "3820222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACEMAKER           6697",
      "code_information": [
        {
          "code": "3820223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 358,
          "minimum": 75.18,
          "maximum": 262.1276,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.1276,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING         FL-601-97",
      "code_information": [
        {
          "code": "3820226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-LEAD                  6623",
      "code_information": [
        {
          "code": "3820227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 255.5378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-BALLOON WEDGE PRESSURE",
      "code_information": [
        {
          "code": "3820550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 703.6442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-ATH-GUIDE 8F",
      "code_information": [
        {
          "code": "3821029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUIDE 6FR",
      "code_information": [
        {
          "code": "3821056",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUIDE 6F",
      "code_information": [
        {
          "code": "3821057",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-GUID 7FR",
      "code_information": [
        {
          "code": "3821245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 162,
          "minimum": 34.02,
          "maximum": 118.6164,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 118.6164,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-DX 6F",
      "code_information": [
        {
          "code": "3822765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOGRAM,BALLOON     6215",
      "code_information": [
        {
          "code": "3823025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1044,
          "minimum": 219.24,
          "maximum": 764.4168,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 764.4168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE           MAP500",
      "code_information": [
        {
          "code": "3823431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-SAFEGUARD PRES  D82000D",
      "code_information": [
        {
          "code": "3823437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 738,
          "minimum": 154.98,
          "maximum": 540.3636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 540.3636,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-RADIAL COMP 24CM   3524",
      "code_information": [
        {
          "code": "3823443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL 5FR 20CM G00972",
      "code_information": [
        {
          "code": "3823451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-STATLOCK   D684000472",
      "code_information": [
        {
          "code": "3823520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 270,
          "minimum": 56.7,
          "maximum": 197.694,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 197.694,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENVELOPE-TYRX ABSORB CMRM6133",
      "code_information": [
        {
          "code": "3823584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5049,
          "minimum": 1060.29,
          "maximum": 3696.8778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3696.8778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAGONFLY OPTIS    C40864x",
      "code_information": [
        {
          "code": "3824115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3181,
          "minimum": 668.01,
          "maximum": 2329.1282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2329.1282,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION          LNQTOOL",
      "code_information": [
        {
          "code": "3824170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 605.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION  D884-00-0019-13",
      "code_information": [
        {
          "code": "3824174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 861.7994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION  D884-00-0019-17",
      "code_information": [
        {
          "code": "3824175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1177,
          "minimum": 247.17,
          "maximum": 861.7994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 861.7994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACCESSORY     518-027",
      "code_information": [
        {
          "code": "3824178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1514,
          "minimum": 317.94,
          "maximum": 1108.5508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1108.5508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INJECTION     ART700SYR",
      "code_information": [
        {
          "code": "3824179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 166,
          "minimum": 34.86,
          "maximum": 121.5452,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 121.5452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD ACC 17L         6056M",
      "code_information": [
        {
          "code": "3824181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LEAD CAP           5867-3M",
      "code_information": [
        {
          "code": "3824183",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 344,
          "minimum": 72.24,
          "maximum": 251.8768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.8768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-INTELL SYR   K05-00626F",
      "code_information": [
        {
          "code": "3824184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SURGIFLO 8ML          2991",
      "code_information": [
        {
          "code": "3824205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1355,
          "minimum": 284.55,
          "maximum": 992.131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 992.131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET             6057-45",
      "code_information": [
        {
          "code": "3824219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SERVICE WRENCH       5873W",
      "code_information": [
        {
          "code": "3824221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 526,
          "minimum": 110.46,
          "maximum": 385.1372,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 385.1372,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PINCH-ON-TOOL         6056",
      "code_information": [
        {
          "code": "3824225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET PACEMAKER   60xx-xx",
      "code_information": [
        {
          "code": "3824226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-STYLET             6091-53",
      "code_information": [
        {
          "code": "3824228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 382,
          "minimum": 80.22,
          "maximum": 279.7004,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 279.7004,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBRICANT-ROTAGLIDE  23548-001",
      "code_information": [
        {
          "code": "3824246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 927,
          "minimum": 194.67,
          "maximum": 678.7494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 678.7494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MANIFOLD-THREE PORT 203BN-R",
      "code_information": [
        {
          "code": "3824285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 75,
          "minimum": 15.75,
          "maximum": 54.915,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.915,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MULTIPAC-4FR SHEATH   538-493P",
      "code_information": [
        {
          "code": "3824294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 417,
          "minimum": 87.57,
          "maximum": 305.3274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 305.3274,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-18G BARE          78050",
      "code_information": [
        {
          "code": "3824350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1037,
          "minimum": 217.77,
          "maximum": 759.2914,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 759.2914,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSEPTAL BRK-1 407201",
      "code_information": [
        {
          "code": "3824358",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1765,
          "minimum": 370.65,
          "maximum": 1292.333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1292.333,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRANSEPTAL       G02364",
      "code_information": [
        {
          "code": "3824360",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1241,
          "minimum": 260.61,
          "maximum": 908.6602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 908.6602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV FINAL    DS2C01",
      "code_information": [
        {
          "code": "3824368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 956.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-CPS UNIV SLITTER  DS2A003",
      "code_information": [
        {
          "code": "3824369",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 409,
          "minimum": 85.89,
          "maximum": 299.4698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 299.4698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-D-STAT DRY CLEAR    3005",
      "code_information": [
        {
          "code": "3824415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-DEFIBRILLATOR        6998",
      "code_information": [
        {
          "code": "3824426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 827,
          "minimum": 173.67,
          "maximum": 605.5294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 605.5294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-PIN DF-1             6996",
      "code_information": [
        {
          "code": "3824428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 349,
          "minimum": 73.29,
          "maximum": 255.5378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 255.5378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUBING SMARTABLATE  SAT001",
      "code_information": [
        {
          "code": "3824441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 961,
          "minimum": 201.81,
          "maximum": 703.6442,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 703.6442,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICROPUNCTURE     S-MAK401",
      "code_information": [
        {
          "code": "3824445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 427,
          "minimum": 89.67,
          "maximum": 312.6494,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 312.6494,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-GLIDE 6FR   RM*BF6M10MA",
      "code_information": [
        {
          "code": "3824476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 456,
          "minimum": 95.76,
          "maximum": 333.8832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 333.8832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-SAFE ALL SZS CLS-10xx.x",
      "code_information": [
        {
          "code": "3824605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INTRODUCER     CLS-250x",
      "code_information": [
        {
          "code": "3824621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 359,
          "minimum": 75.39,
          "maximum": 262.8598,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 262.8598,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-INJECTOR 150 C853-6150",
      "code_information": [
        {
          "code": "3824642",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 88,
          "minimum": 18.48,
          "maximum": 64.4336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.4336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0 27\\\"    J427H",
      "code_information": [
        {
          "code": "3824649",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 62,
          "minimum": 13.02,
          "maximum": 45.3964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.3964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-OXIMAX ADHESIVE MAXA",
      "code_information": [
        {
          "code": "3824663",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 241,
          "minimum": 50.61,
          "maximum": 176.4602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 176.4602,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-STATLOCK PSI 0684-00-'s",
      "code_information": [
        {
          "code": "3824681",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 317,
          "minimum": 66.57,
          "maximum": 232.1074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.1074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PXR35",
      "code_information": [
        {
          "code": "3824705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 110,
          "minimum": 23.1,
          "maximum": 80.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 80.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-UNIVERSAL      6232ADJ",
      "code_information": [
        {
          "code": "3824709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLITTER-UNIVERSAL      6230UNI",
      "code_information": [
        {
          "code": "3824710",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-CONNECTOR PSA EX3151",
      "code_information": [
        {
          "code": "3824711",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1045,
          "minimum": 219.45,
          "maximum": 765.149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 765.149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STERILE 30CM     406500",
      "code_information": [
        {
          "code": "3824713",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 144,
          "minimum": 30.24,
          "maximum": 105.4368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 105.4368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRT XSOFT 59CM 5005",
      "code_information": [
        {
          "code": "3824883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-LONG SOFT 59CM 5014",
      "code_information": [
        {
          "code": "3824884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 597,
          "minimum": 125.37,
          "maximum": 437.1234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.1234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-RUST            6054-58",
      "code_information": [
        {
          "code": "3824889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 319,
          "minimum": 66.99,
          "maximum": 233.5718,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 233.5718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-CONTROL 20ML    CCS320",
      "code_information": [
        {
          "code": "3824955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 64,
          "minimum": 13.44,
          "maximum": 46.8608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.8608,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-FLUID WASTE    64000936",
      "code_information": [
        {
          "code": "3824996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 298,
          "minimum": 62.58,
          "maximum": 218.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 218.1956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-FLEXTEND FIXATION    6616",
      "code_information": [
        {
          "code": "3825028",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-CONTRAST        HPF480K",
      "code_information": [
        {
          "code": "3825032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 85,
          "minimum": 17.85,
          "maximum": 62.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PASSAGE HEMOSTAS  MAP112",
      "code_information": [
        {
          "code": "3825048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 198,
          "minimum": 41.58,
          "maximum": 144.9756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 144.9756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-TORQUE             6628",
      "code_information": [
        {
          "code": "3825085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 498,
          "minimum": 104.58,
          "maximum": 364.6356,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 364.6356,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-GLIDEWIRE INSERT   MAP550",
      "code_information": [
        {
          "code": "3825086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 57,
          "minimum": 11.97,
          "maximum": 41.7354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.7354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-HIGH PRES 20\\\"   HPF200E",
      "code_information": [
        {
          "code": "3825097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 77,
          "minimum": 16.17,
          "maximum": 56.3794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.3794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PEDAL MICROPUNCTURE G02972",
      "code_information": [
        {
          "code": "3825123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 717,
          "minimum": 150.57,
          "maximum": 524.9874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.9874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-PACEMAKER ALL",
      "code_information": [
        {
          "code": "3825190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 598,
          "minimum": 125.58,
          "maximum": 437.8556,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 437.8556,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.0X150MM 390142",
      "code_information": [
        {
          "code": "3900001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.4X150MM SS 390162",
      "code_information": [
        {
          "code": "3900002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 141,
          "minimum": 29.61,
          "maximum": 103.2402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 103.2402,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X55X32MM 608455",
      "code_information": [
        {
          "code": "3900059",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X60X16MM 608260",
      "code_information": [
        {
          "code": "3900060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X60X32MM 608460",
      "code_information": [
        {
          "code": "3900061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X65X16MM 608265",
      "code_information": [
        {
          "code": "3900062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X65X32MM 608465",
      "code_information": [
        {
          "code": "3900063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X70X16MM 608270",
      "code_information": [
        {
          "code": "3900064",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X70X32MM 608470",
      "code_information": [
        {
          "code": "3900065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X75X16MM 608275",
      "code_information": [
        {
          "code": "3900066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X75X32MM 608475",
      "code_information": [
        {
          "code": "3900067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X80X16MM 608280",
      "code_information": [
        {
          "code": "3900068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X80X32MM 608480",
      "code_information": [
        {
          "code": "3900069",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X85X16MM 608285",
      "code_information": [
        {
          "code": "3900070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X85X32MM 608485",
      "code_information": [
        {
          "code": "3900071",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X90X16MM 608290",
      "code_information": [
        {
          "code": "3900072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X90X32MM 608490",
      "code_information": [
        {
          "code": "3900073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X95X16MM 608295",
      "code_information": [
        {
          "code": "3900074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC 6.0X95X32MM 608495",
      "code_information": [
        {
          "code": "3900075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X20MM 608020",
      "code_information": [
        {
          "code": "3900076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X30MM 608030",
      "code_information": [
        {
          "code": "3900077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X35MM 608035",
      "code_information": [
        {
          "code": "3900078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X45MM 608045",
      "code_information": [
        {
          "code": "3900079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X50MM 608050",
      "code_information": [
        {
          "code": "3900080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X55MM 608055",
      "code_information": [
        {
          "code": "3900081",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X65MM 608065",
      "code_information": [
        {
          "code": "3900082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1230,
          "minimum": 258.3,
          "maximum": 900.606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 900.606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X75MM 608075",
      "code_information": [
        {
          "code": "3900083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X80MM 608080",
      "code_information": [
        {
          "code": "3900084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X90MM 608090",
      "code_information": [
        {
          "code": "3900085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANC FT 6.0X95MM 608095",
      "code_information": [
        {
          "code": "3900086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 1.7MM 59-17049E",
      "code_information": [
        {
          "code": "3900087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 2.3MM 59-23049E",
      "code_information": [
        {
          "code": "3900088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WASHER-SCREW 2.3MM 619915",
      "code_information": [
        {
          "code": "3900089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X120MM 5079-6-120",
      "code_information": [
        {
          "code": "3900090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X150MM 5079-6-150",
      "code_information": [
        {
          "code": "3900091",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X30MM 5079-6-030",
      "code_information": [
        {
          "code": "3900092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X40MM 5079-6-040",
      "code_information": [
        {
          "code": "3900093",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X50MM 5079-6-050",
      "code_information": [
        {
          "code": "3900094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X60MM 5079-6-060",
      "code_information": [
        {
          "code": "3900095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROD-CONNT 3X90MM 5079-6-090",
      "code_information": [
        {
          "code": "3900096",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 5X200/60TH 5018-6-200",
      "code_information": [
        {
          "code": "3900097",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2X36/15TH 5065-3-615",
      "code_information": [
        {
          "code": "3900098",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 363,
          "minimum": 76.23,
          "maximum": 265.7886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 265.7886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2X45/20TH 5065-4-520",
      "code_information": [
        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-APEX 2X90/15TH 5065-9-015",
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          "code": "3900100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 159.39,
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X300MM 702626",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    {
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          "code": "0270",
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        }
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        {
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          ]
        }
      ],
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        {
          "code": "0270",
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        }
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        {
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          ]
        }
      ],
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        {
          "code": "0270",
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        }
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        {
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            }
          ]
        }
      ],
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        },
        {
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        }
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        {
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          ]
        }
      ],
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        },
        {
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        }
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        {
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            }
          ]
        }
      ],
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    {
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        },
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        }
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            }
          ]
        }
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    {
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        },
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        }
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            }
          ]
        }
      ],
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        },
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        }
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          ]
        }
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        }
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        }
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        }
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          ]
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      ],
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        }
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          ]
        }
      ],
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          ]
        }
      ],
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          ]
        }
      ],
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          ]
        }
      ],
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    },
    {
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        },
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            }
          ]
        }
      ],
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    },
    {
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        {
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          ]
        }
      ],
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    },
    {
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        {
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          ]
        }
      ],
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    {
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        {
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      ],
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        {
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          ]
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    {
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        {
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      ],
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          ]
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        {
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        },
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          ]
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      ],
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    },
    {
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        {
          "code": "0270",
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        {
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            {
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      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
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        }
      ],
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            }
          ]
        }
      ],
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        {
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          ]
        }
      ],
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    {
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        {
          "code": "0270",
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        }
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          ]
        }
      ],
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    {
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        },
        {
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        {
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    {
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        {
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        {
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          ]
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          ]
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          ]
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          ]
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        }
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        {
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        {
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-EMERG 2.5X6MM 663906",
      "code_information": [
        {
          "code": "3900209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1199,
          "minimum": 251.79,
          "maximum": 877.9078,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 877.9078,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 4.0X26MM 604626",
      "code_information": [
        {
          "code": "3900210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1743,
          "minimum": 366.03,
          "maximum": 1276.2246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1276.2246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 4.0X28MM 604628",
      "code_information": [
        {
          "code": "3900211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1786,
          "minimum": 375.06,
          "maximum": 1307.7092,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1307.7092,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POST-ANGLE 11MM 4922-2-120",
      "code_information": [
        {
          "code": "3900212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1006,
          "minimum": 211.26,
          "maximum": 736.5932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 736.5932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 4.0X95MM 661095",
      "code_information": [
        {
          "code": "3900214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 414.4252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X14MM 661114",
      "code_information": [
        {
          "code": "3900215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 414.4252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X16MM 661116",
      "code_information": [
        {
          "code": "3900216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 414.4252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X18MM 661118",
      "code_information": [
        {
          "code": "3900217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 414.4252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X20MM 661120",
      "code_information": [
        {
          "code": "3900218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 566,
          "minimum": 118.86,
          "maximum": 414.4252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 414.4252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 5.0X95MM 661195",
      "code_information": [
        {
          "code": "3900220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X20MM 601620",
      "code_information": [
        {
          "code": "3900221",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X22MM 601622",
      "code_information": [
        {
          "code": "3900222",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X24MM 601624",
      "code_information": [
        {
          "code": "3900223",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X28MM 601628",
      "code_information": [
        {
          "code": "3900224",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X34MM 601634",
      "code_information": [
        {
          "code": "3900225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X36MM 601636",
      "code_information": [
        {
          "code": "3900226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 5X44MM 601644",
      "code_information": [
        {
          "code": "3900227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X6MM 662506",
      "code_information": [
        {
          "code": "3900239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X7MM 662507",
      "code_information": [
        {
          "code": "3900240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 1.7X9MM 662509",
      "code_information": [
        {
          "code": "3900241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X14MM 663714",
      "code_information": [
        {
          "code": "3900242",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X15MM 663715",
      "code_information": [
        {
          "code": "3900243",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X18MM 663718",
      "code_information": [
        {
          "code": "3900244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X20MM 663720",
      "code_information": [
        {
          "code": "3900245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X22MM 663722",
      "code_information": [
        {
          "code": "3900246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X24MM 663724",
      "code_information": [
        {
          "code": "3900247",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.3X26MM 663726",
      "code_information": [
        {
          "code": "3900248",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1005,
          "minimum": 211.05,
          "maximum": 735.861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X30MM 656030",
      "code_information": [
        {
          "code": "3900263",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1043,
          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 763.6846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X32MM 656032",
      "code_information": [
        {
          "code": "3900264",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X34MM 656034",
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        {
          "code": "3900265",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 219.03,
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          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X36MM 656036",
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        {
          "code": "3900266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 219.03,
          "maximum": 763.6846,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X38MM 656038",
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        {
          "code": "3900267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 219.03,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.4X8MM 656008",
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        {
          "code": "3900268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X30MM 656330",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X32MM 656332",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X36MM 656336",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 6.5X65MM 602865",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANN 8.0X40MM 611040",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANN 8.0X45MM 611045",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 763.6846,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 8.0X50MM 611050",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 763.6846,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 8.0X55MM 611055",
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        {
          "code": "3900290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-CANN 8.0X60MM 611060",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANN 8.0X65MM 611065",
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        },
        {
          "code": "0270",
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        }
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            {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-CANN 8.0X70MM 611070",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X14MM 657614",
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        {
          "code": "3900296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 966,
          "minimum": 202.86,
          "maximum": 707.3052,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 707.3052,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X24MM 657624",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 434.07,
          "maximum": 1513.4574,
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X26MM 657626",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.0X30MM 657630",
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        },
        {
          "code": "0270",
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        }
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          ]
        }
      ],
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    },
    {
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        },
        {
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        }
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    {
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        },
        {
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          ]
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    },
    {
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        },
        {
          "code": "0270",
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        }
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          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK 2.0X6MM 657606",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X7MM 657607",
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        {
          "code": "3900311",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X8MM 657608",
      "code_information": [
        {
          "code": "3900312",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.0X9MM 657609",
      "code_information": [
        {
          "code": "3900313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X11MM 656011",
      "code_information": [
        {
          "code": "3900314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X13MM 656013",
      "code_information": [
        {
          "code": "3900315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X15MM 656015",
      "code_information": [
        {
          "code": "3900316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X40MM 656040",
      "code_information": [
        {
          "code": "3900317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X42MM 656042",
      "code_information": [
        {
          "code": "3900318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X44MM 656044",
      "code_information": [
        {
          "code": "3900319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X46MM 656046",
      "code_information": [
        {
          "code": "3900320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X48MM 656048",
      "code_information": [
        {
          "code": "3900321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1183,
          "minimum": 248.43,
          "maximum": 866.1926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 866.1926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X50MM 656050",
      "code_information": [
        {
          "code": "3900322",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 277,
          "minimum": 58.17,
          "maximum": 202.8194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.8194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X55MM 656055",
      "code_information": [
        {
          "code": "3900323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2855,
          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2090.431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X60MM 656060",
      "code_information": [
        {
          "code": "3900324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2855,
          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2090.431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X65MM 656065",
      "code_information": [
        {
          "code": "3900325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2855,
          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2090.431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X70MM 656070",
      "code_information": [
        {
          "code": "3900326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3218,
          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2356.2196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X7MM 656007",
      "code_information": [
        {
          "code": "3900327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3218,
          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2356.2196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.4X9MM 656009",
      "code_information": [
        {
          "code": "3900328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3218,
          "minimum": 675.78,
          "maximum": 2356.2196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2356.2196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X11MM 656311",
      "code_information": [
        {
          "code": "3900329",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1930,
          "minimum": 405.3,
          "maximum": 1413.146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1413.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X13MM 656313",
      "code_information": [
        {
          "code": "3900330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1930,
          "minimum": 405.3,
          "maximum": 1413.146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1413.146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X15MM 656315",
      "code_information": [
        {
          "code": "3900331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2080,
          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X42MM 656342",
      "code_information": [
        {
          "code": "3900332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2080,
          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X44MM 656344",
      "code_information": [
        {
          "code": "3900333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2080,
          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X46MM 656346",
      "code_information": [
        {
          "code": "3900334",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2080,
          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X48MM 656348",
      "code_information": [
        {
          "code": "3900335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2080,
          "minimum": 436.8,
          "maximum": 1522.976,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1522.976,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X55MM 656355",
      "code_information": [
        {
          "code": "3900336",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2792,
          "minimum": 586.32,
          "maximum": 2044.3024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2044.3024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X60MM 656360",
      "code_information": [
        {
          "code": "3900337",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2792,
          "minimum": 586.32,
          "maximum": 2044.3024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2044.3024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X65MM 656365",
      "code_information": [
        {
          "code": "3900338",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2792,
          "minimum": 586.32,
          "maximum": 2044.3024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2044.3024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X7MM 656307",
      "code_information": [
        {
          "code": "3900341",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2227,
          "minimum": 467.67,
          "maximum": 1630.6094,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1630.6094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK 2.7X9MM 656309",
      "code_information": [
        {
          "code": "3900342",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 620.76,
          "maximum": 2164.3832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2164.3832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X18MM 657018",
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        {
          "code": "3900343",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3646,
          "minimum": 765.66,
          "maximum": 2669.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2669.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X22MM 657022",
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        {
          "code": "3900344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 910.56,
          "maximum": 3174.8192,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3174.8192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X26MM 657026",
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        {
          "code": "3900345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "maximum": 2164.3832,
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X28MM 657028",
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        {
          "code": "3900346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 467.67,
          "maximum": 1630.6094,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1630.6094,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X30MM 657030",
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        {
          "code": "3900347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X32MM 657032",
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        {
          "code": "3900348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2164.3832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X34MM 657034",
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        {
          "code": "3900349",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2164.3832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X36MM 657036",
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        {
          "code": "3900350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2669.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X38MM 657038",
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        {
          "code": "3900351",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X40MM 657040",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X42MM 657042",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X44MM 657044",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X46MM 657046",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 2.7X48MM 657048",
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        {
          "code": "3900356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 460.95,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X50MM 657050",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X60MM 657060",
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        {
          "code": "3900359",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X65MM 657065",
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        {
          "code": "3900360",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X70MM 657070",
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        {
          "code": "3900361",
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        },
        {
          "code": "0270",
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        }
      ],
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 2.7X8MM 657008",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SCREW-LOCK FT 3.5X70MM 657370",
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        {
          "code": "3900364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-WIRE K 2.0X200MM 705135",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEED 2.0X30MM AO 703892",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 73.71,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SPEED 2.6X30MM AO 703894",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 81.48,
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-10101",
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        {
          "code": "3900375",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 5775,
          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4228.455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-10102",
      "code_information": [
        {
          "code": "3900376",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1212.75,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/1.7MM 57-05210",
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        {
          "code": "3900377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4228.455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 8H/2.3 57-10161",
      "code_information": [
        {
          "code": "3900378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5775,
          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4228.455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 10H/2.3MM 57-13442",
      "code_information": [
        {
          "code": "3900379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5775,
          "minimum": 1212.75,
          "maximum": 4228.455,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4228.455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/2.3MM 57-13402",
      "code_information": [
        {
          "code": "3900380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1212.75,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4228.455,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP L 6H/2.3MM 57-13420",
      "code_information": [
        {
          "code": "3900384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6482,
          "minimum": 1361.22,
          "maximum": 4746.1204,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4746.1204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-13451",
      "code_information": [
        {
          "code": "3900388",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
          "gross_charge": 6482,
          "minimum": 1361.22,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4746.1204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/LT 57-10121",
      "code_information": [
        {
          "code": "3900394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5392,
          "minimum": 1132.32,
          "maximum": 3948.0224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3948.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 7H/2.3 57-10160",
      "code_information": [
        {
          "code": "3900397",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 6066,
          "minimum": 1273.86,
          "maximum": 4441.5252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4441.5252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Y 7H/2.37 57-10170",
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        {
          "code": "3900398",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1132.32,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 16H/1.7MM 57-05216",
      "code_information": [
        {
          "code": "3900404",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 1H/1.7MM 57-05285",
      "code_information": [
        {
          "code": "3900405",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3948.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/1.7 57-05291",
      "code_information": [
        {
          "code": "3900408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4441.5252,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/1.7 57-05292",
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        {
          "code": "3900409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/1.7/RT 57-05282",
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        {
          "code": "3900412",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 9H/1.7MM 57-05279",
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        {
          "code": "3900413",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/2.3/LT 57-10483",
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        {
          "code": "3900415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4441.5252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/2.3/RT 57-10482",
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        {
          "code": "3900416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1132.32,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3948.0224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP T 6H/2.3MM 57-10440",
      "code_information": [
        {
          "code": "3900419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP- 6H/2.3MM 57-10407",
      "code_information": [
        {
          "code": "3900422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 1273.86,
          "maximum": 4441.5252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4441.5252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-PIN TO ROD 4960-1-020",
      "code_information": [
        {
          "code": "3900423",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2857,
          "minimum": 599.97,
          "maximum": 2091.8954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2091.8954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-ROD TO ROD 4960-1-010",
      "code_information": [
        {
          "code": "3900424",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 599.97,
          "maximum": 2091.8954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2091.8954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN 4960-2-020",
      "code_information": [
        {
          "code": "3900425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 599.97,
          "maximum": 2091.8954,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2091.8954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-MULTI-PIN 90° 4960-2-030",
      "code_information": [
        {
          "code": "3900426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 599.97,
          "maximum": 2091.8954,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2091.8954,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-ROD TO ROD 4960-1-060",
      "code_information": [
        {
          "code": "3900427",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3232,
          "minimum": 678.72,
          "maximum": 2366.4704,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2366.4704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 12H/143MM",
      "code_information": [
        {
          "code": "3900428",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3412,
          "minimum": 716.52,
          "maximum": 2498.2664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2498.2664,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/1.7MM 57-10304",
      "code_information": [
        {
          "code": "3900429",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "maximum": 2498.2664,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2498.2664,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-15301",
      "code_information": [
        {
          "code": "3900430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2729.6416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4H/2.3MM 57-15302",
      "code_information": [
        {
          "code": "3900431",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2729.6416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/LT 57-10321",
      "code_information": [
        {
          "code": "3900432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2729.6416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/1.7/RT 57-10320",
      "code_information": [
        {
          "code": "3900433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "outpatient",
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          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2729.6416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/LT 57-15321",
      "code_information": [
        {
          "code": "3900434",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3728,
          "minimum": 782.88,
          "maximum": 2729.6416,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2729.6416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 6H/2.3/RT 57-15320",
      "code_information": [
        {
          "code": "3900435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3654.4102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND T 6H/1.7MM 57-10340",
      "code_information": [
        {
          "code": "3900436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 3232,
          "minimum": 678.72,
          "maximum": 2366.4704,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2366.4704,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 16H/2.3MM 57-10116",
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        {
          "code": "3900437",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4044,
          "minimum": 849.24,
          "maximum": 2961.0168,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2961.0168,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3D 2X2+2H 57-10197",
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        {
          "code": "3900438",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 2961.0168,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3D 4X2H 57-10195",
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        {
          "code": "3900439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 3X2H/2.3MM 57-10191",
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        {
          "code": "3900440",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 4X2H/2.3MM 57-10192",
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        {
          "code": "3900441",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3192.392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 13H/2.3 57-10179",
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        {
          "code": "3900442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3192.392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 10H/2X54MM 629610",
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        {
          "code": "3900443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4360,
          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3192.392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 4H/2X22MM 629604",
      "code_information": [
        {
          "code": "3900444",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 915.6,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 5H 629505",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 1048.11,
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-PIN TO ROD 4922-1-020",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 1114.47,
          "maximum": 3885.7854,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3885.7854,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 10H/2.4X66MM 629670",
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        {
          "code": "3900447",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2729.6416,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 20H/2X108MM 629620",
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        {
          "code": "3900448",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2729.6416,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 4H/2.4X26MM 629664",
      "code_information": [
        {
          "code": "3900449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2729.6416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 6H/2.4X40MM 629666",
      "code_information": [
        {
          "code": "3900450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "minimum": 915.6,
          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3192.392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 8H/2.4X53MM 629668",
      "code_information": [
        {
          "code": "3900451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
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          "maximum": 3192.392,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-PIN TO ROD 4922-1-030",
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          "code": "3900452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3192.392,
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUPLING-ROD TO ROD 4922-1-010",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-PRO 20H/2.4X132MM 629680",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-PIN 5H 4922-2-020",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3MM 57-10185",
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        },
        {
          "code": "0270",
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        }
      ],
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 5H/2.3MM 57-13185",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 16H/1.7MM 57-10316",
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        {
          "code": "3900458",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2+2H/1.7 57-10397",
      "code_information": [
        {
          "code": "3900459",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 5623,
          "minimum": 1180.83,
          "maximum": 4117.1606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4117.1606,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/1.7 57-10390",
      "code_information": [
        {
          "code": "3900460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3654.4102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND 2X2H/2.3 57-15390",
      "code_information": [
        {
          "code": "3900461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 4991,
          "minimum": 1048.11,
          "maximum": 3654.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3654.4102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HAND Z 9H/1.7MM 57-10379",
      "code_information": [
        {
          "code": "3900474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 14H/167MM",
      "code_information": [
        {
          "code": "3900475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TUB 1/3 16H/191MM",
      "code_information": [
        {
          "code": "3900476",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 10H/2X57MM 629630",
      "code_information": [
        {
          "code": "3900477",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 6H/2X34MM 629626",
      "code_information": [
        {
          "code": "3900478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE- LOCK 8H/2X46MM 629628",
      "code_information": [
        {
          "code": "3900479",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2X23MM 629624",
      "code_information": [
        {
          "code": "3900480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 10H 629560",
      "code_information": [
        {
          "code": "3900481",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 9H 629559",
      "code_information": [
        {
          "code": "3900482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 10H 629510",
      "code_information": [
        {
          "code": "3900483",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP STRAIGHT 8H 629548",
      "code_information": [
        {
          "code": "3900484",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR LONG LT 54-25405",
      "code_information": [
        {
          "code": "3900499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR LONG RT 54-25404",
      "code_information": [
        {
          "code": "3900500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR SHORT LT 54-25403",
      "code_information": [
        {
          "code": "3900501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ULNAR SHORT RT 54-25402",
      "code_information": [
        {
          "code": "3900502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.4X69MM 629690",
      "code_information": [
        {
          "code": "3900503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 4H/2.4X28 629684",
      "code_information": [
        {
          "code": "3900504",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 6H/2.4X41MM 629686",
      "code_information": [
        {
          "code": "3900505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 8H/2.4X56MM 629688",
      "code_information": [
        {
          "code": "3900506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/150MM 629512",
      "code_information": [
        {
          "code": "3900507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/174MM 629514",
      "code_information": [
        {
          "code": "3900508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 11H 629561",
      "code_information": [
        {
          "code": "3900509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 12H 629562",
      "code_information": [
        {
          "code": "3900510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP CURVED 14H 629564",
      "code_information": [
        {
          "code": "3900511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 10H/2.4X80 629710",
      "code_information": [
        {
          "code": "3900512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 3X5H/2.7X47MM 629784",
      "code_information": [
        {
          "code": "3900530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 5X10H/2.7X87MM 629787",
      "code_information": [
        {
          "code": "3900531",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TRI 10H/2.4X81MM 629791",
      "code_information": [
        {
          "code": "3900532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-Y 10H/2.4X81MM 629790",
      "code_information": [
        {
          "code": "3900533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 12H/2.7X108 629752",
      "code_information": [
        {
          "code": "3900534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LOCK 14H/2.7X125 629754",
      "code_information": [
        {
          "code": "3900535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL STD LT 54-25291",
      "code_information": [
        {
          "code": "3900536",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL STD RT 54-25290",
      "code_information": [
        {
          "code": "3900537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL WIDE LT 54-25293",
      "code_information": [
        {
          "code": "3900538",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL WIDE RT 54-25292",
      "code_information": [
        {
          "code": "3900539",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/LT 628303",
      "code_information": [
        {
          "code": "3900540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/RT 629323",
      "code_information": [
        {
          "code": "3900541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/80MM/RT/629263",
      "code_information": [
        {
          "code": "3900542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/84MM/LT 629203",
      "code_information": [
        {
          "code": "3900543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 3H/84MM/RT 629223",
      "code_information": [
        {
          "code": "3900544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 3H 629283",
      "code_information": [
        {
          "code": "3900545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1082,
          "minimum": 227.22,
          "maximum": 792.2404,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.2404,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-T 10H/2.7X92MM 629788",
      "code_information": [
        {
          "code": "3900546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TRI 10H/2.7X92MM 629789",
      "code_information": [
        {
          "code": "3900547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 4H/5X79MM 627534",
      "code_information": [
        {
          "code": "3900548",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DEC 6H/75MM/LT 628006",
      "code_information": [
        {
          "code": "3900549",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/105MM/LT 629244",
      "code_information": [
        {
          "code": "3900550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/109MM/LT 629204",
      "code_information": [
        {
          "code": "3900551",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/109MM/RT 629204",
      "code_information": [
        {
          "code": "3900552",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/LT 629304",
      "code_information": [
        {
          "code": "3900553",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 4H/RT 629324",
      "code_information": [
        {
          "code": "3900554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1386,
          "minimum": 291.06,
          "maximum": 1014.8292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1014.8292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/128MM/RT 629266",
      "code_information": [
        {
          "code": "3900555",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/132MM /RT 629226",
      "code_information": [
        {
          "code": "3900556",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/132MM/LT 629206",
      "code_information": [
        {
          "code": "3900557",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/LT 629306",
      "code_information": [
        {
          "code": "3900558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 6H/RT 629326",
      "code_information": [
        {
          "code": "3900559",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 4H 629284",
      "code_information": [
        {
          "code": "3900560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 6H 629286",
      "code_information": [
        {
          "code": "3900561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-OLE 6H/113MM/LT 629346",
      "code_information": [
        {
          "code": "3900562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/71MM/RT 627734",
      "code_information": [
        {
          "code": "3900563",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 12H/76MM/RT 54-25385",
      "code_information": [
        {
          "code": "3900564",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 14H/76MM/LT 54-25377",
      "code_information": [
        {
          "code": "3900565",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-VOL 14H/76MM/RT 54-25387",
      "code_information": [
        {
          "code": "3900566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG 54-25296",
      "code_information": [
        {
          "code": "3900567",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG 54-25297",
      "code_information": [
        {
          "code": "3900568",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG LT 54-25295",
      "code_information": [
        {
          "code": "3900569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-DORSAL XLONG RT 54-25294",
      "code_information": [
        {
          "code": "3900570",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 5H/84MM/LT 627705",
      "code_information": [
        {
          "code": "3900571",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 5H/84MM/RT 627735",
      "code_information": [
        {
          "code": "3900572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 5H/5X97MM 627535",
      "code_information": [
        {
          "code": "3900573",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/5X115MM 627536",
      "code_information": [
        {
          "code": "3900574",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 6H/5X119MM 627566",
      "code_information": [
        {
          "code": "3900575",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 6H/97MM/LT 627706",
      "code_information": [
        {
          "code": "3900576",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/97MM/LT 627404",
      "code_information": [
        {
          "code": "3900577",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/97MM/RT 627434",
      "code_information": [
        {
          "code": "3900578",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1392,
          "minimum": 292.32,
          "maximum": 1019.2224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1019.2224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/123MM/LT 627708",
      "code_information": [
        {
          "code": "3900579",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 6H 628406",
      "code_information": [
        {
          "code": "3900580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 7 H 628407",
      "code_information": [
        {
          "code": "3900581",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/LATERAL 8 H 628408",
      "code_information": [
        {
          "code": "3900582",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 10H 628310",
      "code_information": [
        {
          "code": "3900583",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 7 H 628307",
      "code_information": [
        {
          "code": "3900584",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-ANT/MID-SHAFT 8 H 628308",
      "code_information": [
        {
          "code": "3900585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 10H/120MM/RT 628130",
      "code_information": [
        {
          "code": "3900586",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 8H/97MM/LT 628108",
      "code_information": [
        {
          "code": "3900587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC 8H/97MM/RT 628128",
      "code_information": [
        {
          "code": "3900588",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1094,
          "minimum": 229.74,
          "maximum": 801.0268,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.0268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 11H/5X209MM 627571",
      "code_information": [
        {
          "code": "3900590",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1178.842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/5X223MM 627542",
      "code_information": [
        {
          "code": "3900591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1178.842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 12H/5X227MM 627572",
      "code_information": [
        {
          "code": "3900592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1610,
          "minimum": 338.1,
          "maximum": 1178.842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1178.842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 8H/5X155MM 627568",
      "code_information": [
        {
          "code": "3900593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1648.1822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 9H/5X173MM 627569",
      "code_information": [
        {
          "code": "3900594",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1648.1822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/102MM RT 627484",
      "code_information": [
        {
          "code": "3900595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1648.1822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/102MM/LT 627454",
      "code_information": [
        {
          "code": "3900596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2251,
          "minimum": 472.71,
          "maximum": 1648.1822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1648.1822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 13H/5X245MM 627573",
      "code_information": [
        {
          "code": "3900597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1770,
          "minimum": 371.7,
          "maximum": 1295.994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1295.994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/5X259MM 627544",
      "code_information": [
        {
          "code": "3900598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2855,
          "minimum": 599.55,
          "maximum": 2090.431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2090.431,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-COMP 14H/5X263MM 627574",
      "code_information": [
        {
          "code": "3900599",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1495.1524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 6H/127MM/LT 627456",
      "code_information": [
        {
          "code": "3900600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1495.1524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 4H/121MM/LT 627304",
      "code_information": [
        {
          "code": "3900601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1495.1524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 8H/153MM/RT 627488",
      "code_information": [
        {
          "code": "3900602",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2042,
          "minimum": 428.82,
          "maximum": 1495.1524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1495.1524,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/178MM/LT 627460",
      "code_information": [
        {
          "code": "3900603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2047.2312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 6H/RT 628166",
      "code_information": [
        {
          "code": "3900608",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 8H/LT 628148",
      "code_information": [
        {
          "code": "3900609",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-INC BRIDGE 8H/RT 628168",
      "code_information": [
        {
          "code": "3900610",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/199MM/LT 627310",
      "code_information": [
        {
          "code": "3900611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 10H/199MM/RT 627340",
      "code_information": [
        {
          "code": "3900612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 12H/225MM/LT 627312",
      "code_information": [
        {
          "code": "3900613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 12H/225MM/RT 627342",
      "code_information": [
        {
          "code": "3900614",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/139MM 629388",
      "code_information": [
        {
          "code": "3900615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/150MM/LT 629248",
      "code_information": [
        {
          "code": "3900616",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2429,
          "minimum": 510.09,
          "maximum": 1778.5138,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1778.5138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/156MM/LT 629208",
      "code_information": [
        {
          "code": "3900617",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/156MM/RT 629228",
      "code_information": [
        {
          "code": "3900618",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/LT 629308",
      "code_information": [
        {
          "code": "3900619",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/RT 629328",
      "code_information": [
        {
          "code": "3900620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM EXTENDED 8H 629288",
      "code_information": [
        {
          "code": "3900621",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-OLE 8H/137MM/LT 629348",
      "code_information": [
        {
          "code": "3900622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 14H/251MM/LT 627314",
      "code_information": [
        {
          "code": "3900623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-TIB 14H/251MM/RT 627344",
      "code_information": [
        {
          "code": "3900624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 7H/122/LT 628207",
      "code_information": [
        {
          "code": "3900625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-LAT/SUP 7H/122/RT 628227",
      "code_information": [
        {
          "code": "3900626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1915,
          "minimum": 402.15,
          "maximum": 1402.163,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.163,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 10H/176MM/RT 627240",
      "code_information": [
        {
          "code": "3900627",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2047.2312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-HUM 8H/151MM/LT 627208",
      "code_information": [
        {
          "code": "3900628",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2047.2312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 4H/130MM/RT 627634",
      "code_information": [
        {
          "code": "3900630",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 2796,
          "minimum": 587.16,
          "maximum": 2047.2312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2047.2312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 14H/310MM/LT 627614",
      "code_information": [
        {
          "code": "3900636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 411,
          "minimum": 86.31,
          "maximum": 300.9342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 300.9342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 14H/310MM/RT 627644",
      "code_information": [
        {
          "code": "3900637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 411,
          "minimum": 86.31,
          "maximum": 300.9342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 300.9342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLATE-FEM 16H/343MM/RT 627646",
      "code_information": [
        {
          "code": "3900638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1102,
          "minimum": 231.42,
          "maximum": 806.8844,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 806.8844,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-GAIT UNIVERSAL M2616D01",
      "code_information": [
        {
          "code": "4432470",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 95,
          "minimum": 19.95,
          "maximum": 69.559,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.559,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-IC SILVER 16FR 30CC SI16",
      "code_information": [
        {
          "code": "4433340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 135,
          "minimum": 28.35,
          "maximum": 98.847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-TIEMAN FOLEY 12 FR 5CC",
      "code_information": [
        {
          "code": "4435701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 217,
          "minimum": 45.57,
          "maximum": 158.8874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 158.8874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENIPUNCTURE STIK-GUARD",
      "code_information": [
        {
          "code": "4445500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 87,
          "minimum": 18.27,
          "maximum": 63.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.7014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-WOUND POLYMEM 3X1",
      "code_information": [
        {
          "code": "4452250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 61,
          "minimum": 12.81,
          "maximum": 44.6642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.6642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-POLYMEN 4X12 1/2 5124",
      "code_information": [
        {
          "code": "4454125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 159,
          "minimum": 33.39,
          "maximum": 116.4198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 116.4198,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EXT MIC-KEY 0121-24",
      "code_information": [
        {
          "code": "4455449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 152,
          "minimum": 31.92,
          "maximum": 111.2944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.2944,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-DISP SLIPTIP DX",
      "code_information": [
        {
          "code": "4458390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 71,
          "minimum": 14.91,
          "maximum": 51.9862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.9862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RAPID REFILL INJECTION",
      "code_information": [
        {
          "code": "4820306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 335,
          "minimum": 70.35,
          "maximum": 245.287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 245.287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-RX DELIVERY 10FR",
      "code_information": [
        {
          "code": "4820316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-LITHOTRIPTER RX",
      "code_information": [
        {
          "code": "4820525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1712,
          "minimum": 359.52,
          "maximum": 1253.5264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1253.5264,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-RETRIEVAL PULM 0 12/120",
      "code_information": [
        {
          "code": "4820546",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1671,
          "minimum": 350.91,
          "maximum": 1223.5062,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1223.5062,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CLEANING          000336",
      "code_information": [
        {
          "code": "4820730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 268,
          "minimum": 56.28,
          "maximum": 196.2296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.2296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CLEANING 1-1.5MMX1650MM",
      "code_information": [
        {
          "code": "4820735",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 132,
          "minimum": 27.72,
          "maximum": 96.6504,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 96.6504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY BARD     000107",
      "code_information": [
        {
          "code": "4820950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 192,
          "minimum": 40.32,
          "maximum": 140.5824,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 140.5824,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CYTOLOGY RX",
      "code_information": [
        {
          "code": "4821045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1088,
          "minimum": 228.48,
          "maximum": 796.6336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.6336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-MICRO BIOLOGY        130",
      "code_information": [
        {
          "code": "4821100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 272,
          "minimum": 57.12,
          "maximum": 199.1584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 199.1584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-G TUBE ALL SIZES",
      "code_information": [
        {
          "code": "4821257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1029,
          "minimum": 216.09,
          "maximum": 753.4338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 753.4338,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TAPER TIP RX      4577",
      "code_information": [
        {
          "code": "4821690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 878,
          "minimum": 184.38,
          "maximum": 642.8716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 642.8716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAPSULE-BRAVO PH     9012B1011",
      "code_information": [
        {
          "code": "4821720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1947,
          "minimum": 408.87,
          "maximum": 1425.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1425.5934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATHETER-TWISTER PLUS 26MM",
      "code_information": [
        {
          "code": "4822220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 546.9534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMOSTAT RESOLUTION",
      "code_information": [
        {
          "code": "4822320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1306,
          "minimum": 274.26,
          "maximum": 956.2532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 956.2532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LOCKING ERCP RX    4526",
      "code_information": [
        {
          "code": "4822475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 178,
          "minimum": 37.38,
          "maximum": 130.3316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 130.3316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY SUPERTRAX",
      "code_information": [
        {
          "code": "4823755",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 747,
          "minimum": 156.87,
          "maximum": 546.9534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 546.9534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW DISP 1550-40",
      "code_information": [
        {
          "code": "4823800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 275,
          "minimum": 57.75,
          "maximum": 201.355,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 201.355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ANGIOGRAPHIC CATHETER",
      "code_information": [
        {
          "code": "4824510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1284,
          "minimum": 269.64,
          "maximum": 940.1448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 940.1448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDER-SPEED SUPERVIEW 7  4225",
      "code_information": [
        {
          "code": "4824650",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1655,
          "minimum": 347.55,
          "maximum": 1211.791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1211.791,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-MULTIBITE 240 CM   1012",
      "code_information": [
        {
          "code": "4825400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 445,
          "minimum": 93.45,
          "maximum": 325.829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 325.829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR NM-400Y-0423",
      "code_information": [
        {
          "code": "4825501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR   NM-400L-0525",
      "code_information": [
        {
          "code": "4825519",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GAUGE EBUS",
      "code_information": [
        {
          "code": "4825530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 850,
          "minimum": 178.5,
          "maximum": 622.37,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 622.37,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GAUGE EBUS",
      "code_information": [
        {
          "code": "4825535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1150,
          "minimum": 241.5,
          "maximum": 842.03,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 842.03,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ASPIRATION EXCELON  19G",
      "code_information": [
        {
          "code": "4825654",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 896,
          "minimum": 188.16,
          "maximum": 656.0512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-NEEDLE RX F/G",
      "code_information": [
        {
          "code": "4825690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-WANG              MW319",
      "code_information": [
        {
          "code": "4825700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 580,
          "minimum": 121.8,
          "maximum": 424.676,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 424.676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTION 25GA",
      "code_information": [
        {
          "code": "4825701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 383,
          "minimum": 80.43,
          "maximum": 280.4326,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 280.4326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-FOOD BOLUS ROTH   00711155",
      "code_information": [
        {
          "code": "4825703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 915,
          "minimum": 192.15,
          "maximum": 669.963,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 669.963,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-ROTATING RETRIVAL 00711050",
      "code_information": [
        {
          "code": "4825705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 904,
          "minimum": 189.84,
          "maximum": 661.9088,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 661.9088,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 1.5MM 4.5FR 150CM",
      "code_information": [
        {
          "code": "4825995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1567,
          "minimum": 329.07,
          "maximum": 1147.3574,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1147.3574,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD 7 FR           6007",
      "code_information": [
        {
          "code": "4826050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1249,
          "minimum": 262.29,
          "maximum": 914.5178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 914.5178,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL STD 240CM      6232",
      "code_information": [
        {
          "code": "4827202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 202,
          "minimum": 42.42,
          "maximum": 147.9044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-DISP HEXAGON CAPTIVATOR",
      "code_information": [
        {
          "code": "4827315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 209,
          "minimum": 43.89,
          "maximum": 153.0298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 153.0298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-POLYP 00711099",
      "code_information": [
        {
          "code": "4828705",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 170,
          "minimum": 35.7,
          "maximum": 124.474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 124.474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLON DECOMP  CDSG-14-175",
      "code_information": [
        {
          "code": "4829170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1525,
          "minimum": 320.25,
          "maximum": 1116.605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1116.605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 14FR 0100-14LV",
      "code_information": [
        {
          "code": "4829260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22 FR  0100-22",
      "code_information": [
        {
          "code": "4829300",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 374,
          "minimum": 78.54,
          "maximum": 273.8428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 273.8428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 24 FR  0100-24",
      "code_information": [
        {
          "code": "4829350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 378,
          "minimum": 79.38,
          "maximum": 276.7716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 276.7716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 26 FR  0100-26",
      "code_information": [
        {
          "code": "4829400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.8258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-JEJUNOSTOMY 10 FR 30-7361",
      "code_information": [
        {
          "code": "4829700",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 431,
          "minimum": 90.51,
          "maximum": 315.5782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 315.5782,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION ENDOGATOR",
      "code_information": [
        {
          "code": "4829895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 146,
          "minimum": 30.66,
          "maximum": 106.9012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.9012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-AQUAPLAST 12X18 3.2MM",
      "code_information": [
        {
          "code": "5699102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 490,
          "minimum": 102.9,
          "maximum": 358.778,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 358.778,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-UNIFRAME 9X12 MT-APU-12",
      "code_information": [
        {
          "code": "5750063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 389,
          "minimum": 81.69,
          "maximum": 284.8258,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 284.8258,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-PROBE PROSTATE   613-245",
      "code_information": [
        {
          "code": "5995267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 190,
          "minimum": 39.9,
          "maximum": 139.118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 139.118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BARD BIOPSY 12G     121210",
      "code_information": [
        {
          "code": "5995268",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 649,
          "minimum": 136.29,
          "maximum": 475.1978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 475.1978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-NEEDLE ULTRA PRO II",
      "code_information": [
        {
          "code": "5995273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 313,
          "minimum": 65.73,
          "maximum": 229.1786,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.1786,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ULTRASOUND 12GX12CM",
      "code_information": [
        {
          "code": "5995304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 1678,
          "minimum": 352.38,
          "maximum": 1228.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1228.6316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY ALL SZS",
      "code_information": [
        {
          "code": "5995532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 514,
          "minimum": 107.94,
          "maximum": 376.3508,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 376.3508,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY 14X10",
      "code_information": [
        {
          "code": "5995534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 545,
          "minimum": 114.45,
          "maximum": 399.049,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 399.049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 14GAX15C",
      "code_information": [
        {
          "code": "5995547",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 457,
          "minimum": 95.97,
          "maximum": 334.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 334.6154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 14GAX11C",
      "code_information": [
        {
          "code": "5995550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 416,
          "minimum": 87.36,
          "maximum": 304.5952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 304.5952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-H/S PROCEDURE     61-5205",
      "code_information": [
        {
          "code": "5995761",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 584,
          "minimum": 122.64,
          "maximum": 427.6048,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 427.6048,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SERTERA-12GA CORE DEVICE",
      "code_information": [
        {
          "code": "5995763",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SERTERA-14GA CORE DEVICE",
      "code_information": [
        {
          "code": "5995764",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 836,
          "minimum": 175.56,
          "maximum": 612.1192,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 612.1192,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-ENCOR BX SCCAN01",
      "code_information": [
        {
          "code": "7295114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 155,
          "minimum": 32.55,
          "maximum": 113.491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-VAC&RINSE TUBE DS4001",
      "code_information": [
        {
          "code": "7295115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 502,
          "minimum": 105.42,
          "maximum": 367.5644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 367.5644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-ENCOR NEEDLE 7G",
      "code_information": [
        {
          "code": "7295267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 136,
          "minimum": 28.56,
          "maximum": 99.5792,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 99.5792,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MRI SCALPEL/NEEDLE KIT",
      "code_information": [
        {
          "code": "7295418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 312,
          "minimum": 65.52,
          "maximum": 228.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-HS TMI1156",
      "code_information": [
        {
          "code": "7295727",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 99,
          "minimum": 20.79,
          "maximum": 72.4878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.4878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE F/MRI SSQK65/115VS",
      "code_information": [
        {
          "code": "7295730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "outpatient",
          "gross_charge": 239,
          "minimum": 50.19,
          "maximum": 174.9958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.9958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-FEED GENTRI PORT",
      "code_information": [
        {
          "code": "1100160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 76.7418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AIRWAY-LARYN            ALLSZs",
      "code_information": [
        {
          "code": "1100275",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 138,
          "minimum": 47.1774,
          "maximum": 1385.8012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 100.1466,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC PED 10FR    8010",
      "code_information": [
        {
          "code": "1102034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 96.5181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-THORACIC 12FR PEDS   8012",
      "code_information": [
        {
          "code": "1102046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CERV STIFNECK BABY",
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        {
          "code": "1102135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 31.1097,
          "maximum": 426.5287,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CVC 3-LUMEN PWR INJ SAFET",
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        {
          "code": "1110365",
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 201.8643,
          "maximum": 556.6119,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CATH LUMEN 4FR    AK-14402",
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        {
          "code": "1110376",
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        {
          "code": "0270",
          "type": "RC"
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      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 38.927,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
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        }
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      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER CT INJ 19G X .75",
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        {
          "code": "0270",
          "type": "RC"
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        {
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          "maximum": 240.2352,
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              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INTRAOS          G04153",
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
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          "minimum": 147.6856,
          "maximum": 465.4557,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "REMOVER-FOREIGN BODY   FB-5000",
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          "code": "1115735",
          "type": "LOCAL"
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        {
          "code": "0270",
          "type": "RC"
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      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 607.4109,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESUSCITATOR-NEONATE TUBE RESV",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 36.2377,
          "maximum": 911.4479,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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          "code": "1118135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 31.1416,
          "maximum": 1189.4223,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLING-HANGING CAST LG 1180LPP",
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        {
          "code": "1118520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 25.9817,
          "maximum": 55.1532,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPPORT-WRIST ART        29980",
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        {
          "code": "1118720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 22.9049,
          "maximum": 116.781,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "maximum": 636.7345,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "#1855G 5-0 ETHILON PC-1",
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        {
          "code": "1118792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 16.7514,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EVAC/DRAIN 1-BTL  62287",
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          "code": "1118801",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 30.0841,
          "maximum": 188.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFFED       8CFN",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 22.8001,
          "maximum": 246.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 16FR8888266130",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 14.0165,
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SALEM SUMP 18FR 0046180**",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 16.4095,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-15      G00012",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 54.3565,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SPINL 22X20     G03542",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CUSTOM WASTE BAG",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 63.9287,
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            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANISTER-INDIGO W/TUBING IAPS2",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 825.9455,
          "maximum": 2100.3897,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-INFUSION MRI          1056",
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        {
          "code": "1410839",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-SYRINGE ADAPTER MRI   1057",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 72.4754,
          "maximum": 153.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 54.0146,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 18-15      G03954",
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        {
          "code": "1411193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 74.1847,
          "maximum": 549.4268,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MONOPTY 18X10    121810",
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        {
          "code": "1411612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 63.9515,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "JAR-COPLIN PP STAIN     S90130",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 39.3145,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION     CID-20-30",
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        {
          "code": "1412310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 734,
          "minimum": 250.9288,
          "maximum": 631.1735,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TORQUE .010-.038   TD01",
      "code_information": [
        {
          "code": "1412325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 87.3077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-STAYFIX SMALL    680-ME",
      "code_information": [
        {
          "code": "1412330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 53.6728,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.9349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DILATOR-VESSEL ALL 48-100's",
      "code_information": [
        {
          "code": "1412394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 85.0833,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.4102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 18GX ALL SZ",
      "code_information": [
        {
          "code": "1413165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 591,
          "minimum": 202.0421,
          "maximum": 428.8887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 428.8887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MAXCORE 20GX ALL SZ",
      "code_information": [
        {
          "code": "1413170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 523,
          "minimum": 120.6737,
          "maximum": 379.5411,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 379.5411,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FRANSEEN ALL SZS G01xxx",
      "code_information": [
        {
          "code": "1414845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 285.2793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 271.4118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BARD MONOPTY ALL SZS",
      "code_information": [
        {
          "code": "1414866",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 757.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 309.1482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 20-10      G01112",
      "code_information": [
        {
          "code": "1414935",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 115.3863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 115.3863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 17X     C18xxA",
      "code_information": [
        {
          "code": "1414990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 77.9452,
          "maximum": 165.4596,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 165.4596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TRUGUIDE 19X     C20xxA",
      "code_information": [
        {
          "code": "1414995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 205,
          "minimum": 70.0823,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 148.7685,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-IV SILVERSITE 1X7MM",
      "code_information": [
        {
          "code": "1415449",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 2767.7097,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.0906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLUG-VASCULAR 6MM X 7MM X 5FR",
      "code_information": [
        {
          "code": "1415480",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-ENTUIT GASTRO INITIAL SM",
      "code_information": [
        {
          "code": "1415943",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 987,
          "minimum": 337.4206,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 716.2659,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-150 ML ILLUMENA 900103",
      "code_information": [
        {
          "code": "1416100",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 2008.0771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 22FR   0250-22",
      "code_information": [
        {
          "code": "1416370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 396.4993,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1137.1719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FEEDING ENTUIT THRIVE 14F",
      "code_information": [
        {
          "code": "1416371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 713,
          "minimum": 243.7496,
          "maximum": 1623.812,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 517.4241,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-INDIGO             IST3",
      "code_information": [
        {
          "code": "1416377",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2920,
          "minimum": 998.2454,
          "maximum": 2119.044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2119.044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX20C",
      "code_information": [
        {
          "code": "1419101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 312.051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX11C",
      "code_information": [
        {
          "code": "1419112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 372.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 18GX15C",
      "code_information": [
        {
          "code": "1419113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 372.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY 20GX15C",
      "code_information": [
        {
          "code": "1419114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 372.2841,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 372.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 18GAX11C",
      "code_information": [
        {
          "code": "1419116",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 389.7009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX15C",
      "code_information": [
        {
          "code": "1419118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 601,
          "minimum": 205.4608,
          "maximum": 436.1457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 436.1457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TEMNO BIOPSY 20GAX20C",
      "code_information": [
        {
          "code": "1419119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 601,
          "minimum": 205.4608,
          "maximum": 436.1457,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 436.1457,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACHIEVE BIOPSY  20GX11C",
      "code_information": [
        {
          "code": "1419293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 451,
          "minimum": 154.1811,
          "maximum": 556.6561,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 327.2907,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-BIOPSY EVIVA 9G",
      "code_information": [
        {
          "code": "1495152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 39.4831,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1217.7246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-TISSUE ATEC        TF-1",
      "code_information": [
        {
          "code": "1495228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.5247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-EVIVA STX   0913-12T",
      "code_information": [
        {
          "code": "1495304",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 172.9471,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1217.7246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE MULTICARE  MME-00347",
      "code_information": [
        {
          "code": "1495418",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 352.5674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 225.6927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC",
      "code_information": [
        {
          "code": "2395902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 79.827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONCENTRIC 50MM",
      "code_information": [
        {
          "code": "2395904",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 310.8599,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MAT-SURGISAFE ABSORBANT FLOOR",
      "code_information": [
        {
          "code": "3000001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 323,
          "minimum": 110.4223,
          "maximum": 32556.8745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 234.4011,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BONECUTTER-FULL RADIUS 5.5MM",
      "code_information": [
        {
          "code": "3000006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 650.2272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CYSTO               2C4040",
      "code_information": [
        {
          "code": "3000090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CONFIDENCE 2839-99-002",
      "code_information": [
        {
          "code": "3000520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 200.2932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-HEMOSTASES  HC0001",
      "code_information": [
        {
          "code": "3000742",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1597,
          "minimum": 545.9582,
          "maximum": 1158.9429,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1158.9429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-CLIP MED/LG 20 SMC",
      "code_information": [
        {
          "code": "3000753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1007,
          "minimum": 141.8055,
          "maximum": 730.7799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 730.7799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP PK AM0004",
      "code_information": [
        {
          "code": "3000760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 185.0535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.0535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLICATOR-FLEXI-TIP    AM0005",
      "code_information": [
        {
          "code": "3000762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 109.3968,
          "maximum": 11638.0608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP  DISP   MCM20",
      "code_information": [
        {
          "code": "3000765",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 518,
          "minimum": 177.086,
          "maximum": 375.9126,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 375.9126,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP LARGE MCL20",
      "code_information": [
        {
          "code": "3000766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 553,
          "minimum": 189.0513,
          "maximum": 401.3121,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 401.3121,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-LIGACLIP SM MCS20",
      "code_information": [
        {
          "code": "3000767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 569,
          "minimum": 194.5211,
          "maximum": 720.1495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 412.9233,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-AUTOMATIC 5MM AE05ML",
      "code_information": [
        {
          "code": "3000770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 939.7815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "APPLIER-ANASTOCLIP LARGE 15CM",
      "code_information": [
        {
          "code": "3000773",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ASSISTANT-SUTURE 5MM     SW100",
      "code_information": [
        {
          "code": "3000865",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1311,
          "minimum": 448.1848,
          "maximum": 2858.354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 951.3927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-ANCHOR TISSUE ROBOTIC",
      "code_information": [
        {
          "code": "3001135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 649,
          "minimum": 221.8703,
          "maximum": 470.9793,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 470.9793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-ENDOPOUCH 10MM POUCH",
      "code_information": [
        {
          "code": "3001190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 433.2429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-DISPOSA 3MM       DBL-311",
      "code_information": [
        {
          "code": "3001371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 2990.1497,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.8937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-IPRISM IPC05",
      "code_information": [
        {
          "code": "3001669",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 3262.6387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 519.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAR-TIBIAL LOCKING      141205",
      "code_information": [
        {
          "code": "3002092",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1493,
          "minimum": 313.6404,
          "maximum": 1083.4701,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1083.4701,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BASKET-NITINOL 1.9X120 390-201",
      "code_information": [
        {
          "code": "3002152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1576,
          "minimum": 538.779,
          "maximum": 1143.7032,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1143.7032,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CEMENT-COMPACT VACUUM",
      "code_information": [
        {
          "code": "3002214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 99.5419,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 947.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           315.48",
      "code_information": [
        {
          "code": "3002244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1847.3642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1137.1719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 3.2      310.65",
      "code_information": [
        {
          "code": "3002246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3322,
          "minimum": 207.4253,
          "maximum": 2410.7754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2410.7754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-MINI DRILL AT2M-1813",
      "code_information": [
        {
          "code": "3002257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 1578.3975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1578.3975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X145   03.010.104",
      "code_information": [
        {
          "code": "3002260",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1668,
          "minimum": 570.2306,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1210.4676,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    351.27",
      "code_information": [
        {
          "code": "3002270",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3542,
          "minimum": 497.7095,
          "maximum": 2570.4294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2570.4294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 12MM      03.010.036",
      "code_information": [
        {
          "code": "3002274",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3373,
          "minimum": 1153.1102,
          "maximum": 2447.7861,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2447.7861,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM     03.010.060",
      "code_information": [
        {
          "code": "3002289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2190,
          "minimum": 521.0657,
          "maximum": 1589.283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1589.283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5           310.23",
      "code_information": [
        {
          "code": "3002291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 937,
          "minimum": 320.3274,
          "maximum": 679.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 679.9809,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0MM         310.19",
      "code_information": [
        {
          "code": "3002294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 949,
          "minimum": 324.4298,
          "maximum": 688.6893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 688.6893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MMX150MM  511.417",
      "code_information": [
        {
          "code": "3002302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1642,
          "minimum": 561.3421,
          "maximum": 1191.5994,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1191.5994,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2 ALL 1806-4200s",
      "code_information": [
        {
          "code": "3002305",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1134,
          "minimum": 387.6748,
          "maximum": 822.9438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 822.9438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2X180MM 1806-4270S",
      "code_information": [
        {
          "code": "3002306",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 156.8202,
          "maximum": 882.4512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 882.4512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL BURR        5091-206",
      "code_information": [
        {
          "code": "3002318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 63.3954,
          "maximum": 204.6474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 204.6474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-STEP DRILL         357.403",
      "code_information": [
        {
          "code": "3002361",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3578,
          "minimum": 712.9202,
          "maximum": 2596.5546,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2596.5546,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 2.4     310.530",
      "code_information": [
        {
          "code": "3002365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1282,
          "minimum": 438.2708,
          "maximum": 930.3474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 930.3474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           1806-5020S",
      "code_information": [
        {
          "code": "3002379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1219,
          "minimum": 416.7333,
          "maximum": 884.6283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 884.6283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.8MM 03.113.024",
      "code_information": [
        {
          "code": "3002394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1440,
          "minimum": 492.2854,
          "maximum": 1045.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1045.008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM 03.113.023",
      "code_information": [
        {
          "code": "3002399",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1440,
          "minimum": 492.2854,
          "maximum": 1045.008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1045.008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2MM 703542",
      "code_information": [
        {
          "code": "3002400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1284,
          "minimum": 438.9545,
          "maximum": 931.7988,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 931.7988,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.3MM 703541",
      "code_information": [
        {
          "code": "3002402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1335,
          "minimum": 201.8643,
          "maximum": 968.8095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 968.8095,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 5085-2-032",
      "code_information": [
        {
          "code": "3002403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 263.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.0MM 5085-2-040",
      "code_information": [
        {
          "code": "3002410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 263.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL 1.7MM",
      "code_information": [
        {
          "code": "3002760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1755,
          "minimum": 599.9728,
          "maximum": 1273.6035,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1273.6035,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL AO        1806-5000S",
      "code_information": [
        {
          "code": "3002772",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1103,
          "minimum": 377.0769,
          "maximum": 1217.859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 800.4471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM     03.010.061",
      "code_information": [
        {
          "code": "3002776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2190,
          "minimum": 748.684,
          "maximum": 1589.283,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1589.283,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.2MM    03.010.101S",
      "code_information": [
        {
          "code": "3002777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2175,
          "minimum": 743.5561,
          "maximum": 1578.3975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1578.3975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.6x",
      "code_information": [
        {
          "code": "3002779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2769,
          "minimum": 946.6238,
          "maximum": 2009.4633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2009.4633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL W/STOP ALL   324.15x",
      "code_information": [
        {
          "code": "3002780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2797,
          "minimum": 870.8526,
          "maximum": 2029.7829,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2029.7829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-CANNULATED DRILL    310.68",
      "code_information": [
        {
          "code": "3002782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2977,
          "minimum": 497.7095,
          "maximum": 2160.4089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2160.4089,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANN 17MM    357.394",
      "code_information": [
        {
          "code": "3002785",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4976,
          "minimum": 497.7095,
          "maximum": 3611.0832,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3611.0832,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM         700347",
      "code_information": [
        {
          "code": "3002791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1337,
          "minimum": 457.0733,
          "maximum": 970.2609,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 970.2609,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1MM         702742",
      "code_information": [
        {
          "code": "3002793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1019,
          "minimum": 348.3603,
          "maximum": 739.4883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 739.4883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5X110MM     310.35",
      "code_information": [
        {
          "code": "3002794",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 921,
          "minimum": 314.8575,
          "maximum": 668.3697,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 668.3697,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BEAVER MINI       376900",
      "code_information": [
        {
          "code": "3002835",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 33.8446,
          "maximum": 618.9393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 9-9.5MM 5400-031-xxx",
      "code_information": [
        {
          "code": "3002951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1113,
          "minimum": 380.4956,
          "maximum": 807.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 807.7041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-EXT ELECTRODE    E1551-6",
      "code_information": [
        {
          "code": "3002959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 78.3756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-TURBINATE INF SB2000SA",
      "code_information": [
        {
          "code": "3002962",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1139,
          "minimum": 389.3841,
          "maximum": 826.5723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 826.5723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SERRATED STND SB4000SS",
      "code_information": [
        {
          "code": "3002963",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1300,
          "minimum": 60.0588,
          "maximum": 943.41,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 943.41,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MYRINGOTOMY SPEAR TIP",
      "code_information": [
        {
          "code": "3003112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 108,
          "minimum": 36.9214,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 78.3756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RAD 40 DEGREE 18-84006HR",
      "code_information": [
        {
          "code": "3003122",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1727,
          "minimum": 590.4006,
          "maximum": 1253.2839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1253.2839,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RADNOID 18-84008",
      "code_information": [
        {
          "code": "3003123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1721,
          "minimum": 588.3494,
          "maximum": 1248.9297,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1248.9297,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-RASP SAW       510037113",
      "code_information": [
        {
          "code": "3003127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1108,
          "minimum": 289.7281,
          "maximum": 804.0756,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 804.0756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW MICR 9MM 2296-3-100s",
      "code_information": [
        {
          "code": "3003143",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 178.1116,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 378.0897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAG SAW 9X25 ALL 2296s",
      "code_information": [
        {
          "code": "3003147",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 521,
          "minimum": 62.2832,
          "maximum": 378.0897,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 378.0897,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 5.5MMX18MM  KM 3-412",
      "code_information": [
        {
          "code": "3003150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 177.952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW GIGLI ROUND  2808-01",
      "code_information": [
        {
          "code": "3003172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 320,
          "minimum": 33.366,
          "maximum": 232.224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.224,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HEX COATED 2.75   E1450X",
      "code_information": [
        {
          "code": "3003200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 2242.1952,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-INF TURB 2.0  18-82040HR",
      "code_information": [
        {
          "code": "3003227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2469,
          "minimum": 844.0643,
          "maximum": 1791.7533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1791.7533,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90Xxx    05.003.1xxS",
      "code_information": [
        {
          "code": "3003256",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 967.0579,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 452.8368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-QUAD-CUT       1884380HR",
      "code_information": [
        {
          "code": "3003258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1739,
          "minimum": 594.503,
          "maximum": 1772.8468,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1261.9923,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW ALL SZS     519.xxxS",
      "code_information": [
        {
          "code": "3003292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 776,
          "minimum": 265.2871,
          "maximum": 563.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 563.1432,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-CELL SAVER HI SP   CSP26x",
      "code_information": [
        {
          "code": "3003419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 777,
          "minimum": 265.629,
          "maximum": 563.8689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 563.8689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOWL-SMARTMIX CTS    540176501",
      "code_information": [
        {
          "code": "3003433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 513,
          "minimum": 175.3767,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 372.2841,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-INTERNAL AR-1678-CP",
      "code_information": [
        {
          "code": "3003471",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5500,
          "minimum": 554.9878,
          "maximum": 3991.35,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3991.35,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-UNIV X-ACT 11-2151-9",
      "code_information": [
        {
          "code": "3003472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 998,
          "minimum": 89.5321,
          "maximum": 724.2486,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 724.2486,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-WHISTLE CLEANING  000101",
      "code_information": [
        {
          "code": "3003605",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 94.341,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 94.341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT RND 2296-100-421",
      "code_information": [
        {
          "code": "3003756",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 154.5958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.9069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-OVAL CUTTING 5300-010-901",
      "code_information": [
        {
          "code": "3003762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 278,
          "minimum": 95.0384,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 201.7446,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND          277-10-423",
      "code_information": [
        {
          "code": "3003782",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 271.4118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND CUT 2.4MM  5091-225",
      "code_information": [
        {
          "code": "3003786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 66.732,
          "maximum": 175.6194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 175.6194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-CROSS CUT 1.6   277-10-xxx",
      "code_information": [
        {
          "code": "3003792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 347.0064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-WATERMELON      1607-2-35",
      "code_information": [
        {
          "code": "3003805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 708.4714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 452.8368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUTTON-NASAL SEPTAL   SP-7810",
      "code_information": [
        {
          "code": "3003812",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1274,
          "minimum": 435.5358,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 924.5418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ELITE RND 2MM 5820-013-0xx",
      "code_information": [
        {
          "code": "3003829",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 300.294,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 926.7189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-ROUND 4.0MM    277-10-240",
      "code_information": [
        {
          "code": "3003855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.5955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 5MM     5820-013-050",
      "code_information": [
        {
          "code": "3003856",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 990.5805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-PACING BLUE   FL-601-97B",
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        {
          "code": "3003905",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 106.6618,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 226.4184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-LIGHT STERILE MAS PLIF",
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        {
          "code": "3003914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 975.3404,
          "maximum": 5832.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2070.4221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AORTIC ARCH 6.5  80320",
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        {
          "code": "3004042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 123.4132,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 261.9777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO DBL 5MM PAL-505LL",
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          "code": "3004047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 86.1955,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 476.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY PREMATURE",
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        {
          "code": "3004048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 112.4835,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERAPY NEONATAL",
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        {
          "code": "3004049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 112.4835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-O2 THERPAY INFANT",
      "code_information": [
        {
          "code": "3004051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 411.514,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 112.4835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 3MM PAL-308LS",
      "code_information": [
        {
          "code": "3004052",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 537.018,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 537.018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-CURVED 100MM 20G 10.0M",
      "code_information": [
        {
          "code": "3004190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 271.4118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX FEM TFA-022-25",
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        {
          "code": "3004225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 208.1957,
          "maximum": 441.9513,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 441.9513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMFLEX       TFA02025",
      "code_information": [
        {
          "code": "3004226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 208.1957,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-FEMORAL 27FR 96370-027",
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        {
          "code": "3004235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 607.4939,
          "maximum": 1289.5689,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1289.5689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-5FR RAD PIGTAIL 5RPS110-N",
      "code_information": [
        {
          "code": "3004842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 364,
          "minimum": 124.4388,
          "maximum": 1145.0099,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 264.1548,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-TACKER DELIVERY OMS-TTS",
      "code_information": [
        {
          "code": "3005077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3218,
          "minimum": 870.8526,
          "maximum": 2335.3026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2335.3026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-CHLOANGIOGRAM   20018-010",
      "code_information": [
        {
          "code": "3005234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 613,
          "minimum": 110.6639,
          "maximum": 444.8541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 444.8541,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 2/W 24Fr 5CC 265724",
      "code_information": [
        {
          "code": "3005414",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 574.4513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.1705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 3WAY         73022L",
      "code_information": [
        {
          "code": "3005435",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 174,
          "minimum": 59.4845,
          "maximum": 1478.6699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 126.2718,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-PASSER            8591-38",
      "code_information": [
        {
          "code": "3006601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1761.7248,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 34FR-46FR ALL",
      "code_information": [
        {
          "code": "3007230",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 442.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 442.677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-VENOUS 36FR-46FR  TF36460",
      "code_information": [
        {
          "code": "3007235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 610,
          "minimum": 208.5376,
          "maximum": 442.677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 442.677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-HIGH TEMP         AA01",
      "code_information": [
        {
          "code": "3007600",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 178.5081,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 79.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAUTERY-ACU-DISPO      DCFT2",
      "code_information": [
        {
          "code": "3007601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 1595.4509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.9497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP,MULTI-PIN LG 390.004",
      "code_information": [
        {
          "code": "3008494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4727,
          "minimum": 1615.9952,
          "maximum": 3430.3839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3430.3839,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-NV DSC & IN-LINE ACTIVATO",
      "code_information": [
        {
          "code": "3008690",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 432.0897,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1675.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-LAPRA-TY ABS SUTURE XC200",
      "code_information": [
        {
          "code": "3008699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 777,
          "minimum": 52.2734,
          "maximum": 563.8689,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 563.8689,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIPS-HEM-O-LOC         544230",
      "code_information": [
        {
          "code": "3008728",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.2158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK LG       544240",
      "code_information": [
        {
          "code": "3008730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.6046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEM-O-LOK XL       544250",
      "code_information": [
        {
          "code": "3008731",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.5247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-3/8X3/8 XA6062",
      "code_information": [
        {
          "code": "3009659",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 871,
          "minimum": 297.7643,
          "maximum": 2382.3324,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 632.0847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONNECTOR-STR ACCU-FLO 82-1504",
      "code_information": [
        {
          "code": "3009774",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1133,
          "minimum": 387.3329,
          "maximum": 2246.0879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 822.2181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CONSTAVAC-CBC II    225-28-614",
      "code_information": [
        {
          "code": "3009792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1463,
          "minimum": 83.415,
          "maximum": 1061.6991,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1061.6991,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR BOVIE DISP 301538",
      "code_information": [
        {
          "code": "3009842",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 155.708,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-BIPOLAR HIGH   26176LD/10",
      "code_information": [
        {
          "code": "3009843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 1074.9413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 203.196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNULATED",
      "code_information": [
        {
          "code": "3009845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1933,
          "minimum": 660.8248,
          "maximum": 1402.7781,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1402.7781,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-MICRO CANNUL 3.8MM",
      "code_information": [
        {
          "code": "3009850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1799,
          "minimum": 50.049,
          "maximum": 1305.5343,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1305.5343,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-SILICONE RETRACTOR",
      "code_information": [
        {
          "code": "3009851",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 90,
          "minimum": 30.7678,
          "maximum": 158.4885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 65.313,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CORD-DISPOSABLE ACTIVE DAC",
      "code_information": [
        {
          "code": "3009853",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 1787.3054,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 206.8245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-8 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 187.2306,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 187.2306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-12 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009951",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 206.8245,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 206.8245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 10191.6447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.1441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-24 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009956",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 348,
          "minimum": 118.969,
          "maximum": 252.5436,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 252.5436,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-30 DPSB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009957",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 269.9604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUFF-18 DPDB DISP TOURNIQUET",
      "code_information": [
        {
          "code": "3009971",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 428,
          "minimum": 146.3182,
          "maximum": 310.5996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 310.5996,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-MERCEDES     PAL-506LL",
      "code_information": [
        {
          "code": "3010053",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 2360.0884,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 476.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VENOUS ALL SZS   681xx",
      "code_information": [
        {
          "code": "3010076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 551,
          "minimum": 188.3675,
          "maximum": 2007.521,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 399.8607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT ALL SZ",
      "code_information": [
        {
          "code": "3010079",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 382,
          "minimum": 130.5924,
          "maximum": 1508.1432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 277.2174,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL 1X4  2111-04-077",
      "code_information": [
        {
          "code": "3010088",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2712,
          "minimum": 927.1375,
          "maximum": 3166.9895,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1968.0984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRID-CORTICAL ALL  2111-08-07x",
      "code_information": [
        {
          "code": "3010090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5695,
          "minimum": 265.2597,
          "maximum": 4132.8615,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4132.8615,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X20 657320",
      "code_information": [
        {
          "code": "3010104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 988.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-LOCK FT 3.5X40 657340",
      "code_information": [
        {
          "code": "3010107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 988.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-DUBIN              8390",
      "code_information": [
        {
          "code": "3010215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 494.929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 200.2932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION         BID30",
      "code_information": [
        {
          "code": "3010259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 890,
          "minimum": 265.8158,
          "maximum": 645.873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 645.873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-MYOSURE TISSUE REMOVAL",
      "code_information": [
        {
          "code": "3010310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1901.3059,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-LAPARSCOP PLUME FILTER",
      "code_information": [
        {
          "code": "3010330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 198,
          "minimum": 67.6892,
          "maximum": 5379.1553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 143.6886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-VAGINAL POSITIONING",
      "code_information": [
        {
          "code": "3010598",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2367,
          "minimum": 809.1941,
          "maximum": 1717.7319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1717.7319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISSECTOR-BLUNT TIP 5 PK BTD05",
      "code_information": [
        {
          "code": "3010867",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.3303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.1 5901-1126",
      "code_information": [
        {
          "code": "3011002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 207.4253,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 606.6852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-CHAN W/TROCAR ALL SIZES",
      "code_information": [
        {
          "code": "3011730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 199,
          "minimum": 43.3758,
          "maximum": 144.4143,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 144.4143,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-FLAT HUBLESS ALL SZS",
      "code_information": [
        {
          "code": "3011780",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 633.3979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.6046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAIN-MINI CHEST 500     16400",
      "code_information": [
        {
          "code": "3011787",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1139,
          "minimum": 389.3841,
          "maximum": 826.5723,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 826.5723,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FECAL MANAGEMENT 418000",
      "code_information": [
        {
          "code": "3011910",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1469,
          "minimum": 36.1465,
          "maximum": 1066.0533,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1066.0533,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-FECAL MANAGEMENT 411108",
      "code_information": [
        {
          "code": "3011911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 22.2212,
          "maximum": 120.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.1705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-HIP W/POUCHES DYNJP8201",
      "code_information": [
        {
          "code": "3011920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 217,
          "minimum": 74.1847,
          "maximum": 157.4769,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 157.4769,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BEACH CHAIR SHOULDER",
      "code_information": [
        {
          "code": "3011922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 257,
          "minimum": 87.8593,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 186.5049,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-BARIATRIC      DYNJP3105",
      "code_information": [
        {
          "code": "3011926",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 228,
          "minimum": 77.9452,
          "maximum": 271.3768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 165.4596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-DOUBLE 44X66     ORS 320",
      "code_information": [
        {
          "code": "3011927",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 166.8301,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 354.1416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INCISE 3M SHORT   6661EZ",
      "code_information": [
        {
          "code": "3011953",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 19.8282,
          "maximum": 148.4787,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.0906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-ISO IOBAN HIP       6617",
      "code_information": [
        {
          "code": "3011959",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 267,
          "minimum": 91.2779,
          "maximum": 200.196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 193.7619,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INTESTINAL 18X18.5 ISO1003",
      "code_information": [
        {
          "code": "3011960",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 360,
          "minimum": 123.0713,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 261.252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BAG-INZII RETRIEVAL 10MM CD001",
      "code_information": [
        {
          "code": "3011961",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 44.488,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.6308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI     326088-0000-000",
      "code_information": [
        {
          "code": "3011985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 155.1519,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-OPMI FULL         306070",
      "code_information": [
        {
          "code": "3011987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 279,
          "minimum": 95.3803,
          "maximum": 328.6551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.4703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-WARMER           ORS-400",
      "code_information": [
        {
          "code": "3011995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 591,
          "minimum": 33.366,
          "maximum": 428.8887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 428.8887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERI IRRIGATION    1016",
      "code_information": [
        {
          "code": "3012018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 68.9564,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-STERILE HAND   DYNJP8005",
      "code_information": [
        {
          "code": "3012025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 89.9868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 89.9868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-EAR GLASSCOCK  S-1000",
      "code_information": [
        {
          "code": "3012051",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 311,
          "minimum": 106.32,
          "maximum": 266.928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 225.6927,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-GENTLE CARE SURG 12-1",
      "code_information": [
        {
          "code": "3012060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 480,
          "minimum": 164.0951,
          "maximum": 348.336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 348.336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-TOPIFOAM      5710-30",
      "code_information": [
        {
          "code": "3012080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 57.2783,
          "maximum": 216.9843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 216.9843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED ASNIS III",
      "code_information": [
        {
          "code": "3012111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1063.8193,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANNULATED 3.5MM  702450",
      "code_information": [
        {
          "code": "3012114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 673.4371,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-HEX 1.1X67       15-1723",
      "code_information": [
        {
          "code": "3012115",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1211,
          "minimum": 413.9983,
          "maximum": 878.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 878.8227,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.0MM CALIBRATED",
      "code_information": [
        {
          "code": "3012118",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1137.1719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST ASNIS III 6.5MM",
      "code_information": [
        {
          "code": "3012151",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-TWIST CANN 4.0MM W/AO",
      "code_information": [
        {
          "code": "3012152",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5392,
          "minimum": 813.0182,
          "maximum": 3912.9744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3912.9744,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-SHAFT-AO 2.6MMX122MM",
      "code_information": [
        {
          "code": "3012186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1060.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 4.5           310.48",
      "code_information": [
        {
          "code": "3012201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1176,
          "minimum": 402.0331,
          "maximum": 853.4232,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 853.4232,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1806-5010S",
      "code_information": [
        {
          "code": "3012206",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1103,
          "minimum": 377.0769,
          "maximum": 800.4471,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 800.4471,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 03.6MMX122MM",
      "code_information": [
        {
          "code": "3012207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1378,
          "minimum": 471.0898,
          "maximum": 1000.0146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1000.0146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 13.0MM CANNULATED",
      "code_information": [
        {
          "code": "3012314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4464,
          "minimum": 540.5292,
          "maximum": 3239.5248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3239.5248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0         MS-DCR20",
      "code_information": [
        {
          "code": "3012321",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 959.2725,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.0929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 LG 120MM",
      "code_information": [
        {
          "code": "3012325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1725,
          "minimum": 589.7169,
          "maximum": 1251.8325,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1251.8325,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.7 315.28",
      "code_information": [
        {
          "code": "3012330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1374,
          "minimum": 469.7223,
          "maximum": 997.1118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 997.1118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.2X40   2274-12-000",
      "code_information": [
        {
          "code": "3012344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1940,
          "minimum": 586.6855,
          "maximum": 1407.858,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1407.858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 3.5          MS-DC35",
      "code_information": [
        {
          "code": "3012346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1055,
          "minimum": 360.6674,
          "maximum": 765.6135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 765.6135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.201",
      "code_information": [
        {
          "code": "3012355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 912,
          "minimum": 311.7808,
          "maximum": 661.8384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 661.8384,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL               310.28",
      "code_information": [
        {
          "code": "3012356",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 972,
          "minimum": 332.2926,
          "maximum": 784.6571,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 705.3804,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL              310.431",
      "code_information": [
        {
          "code": "3012357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1411,
          "minimum": 482.3713,
          "maximum": 1023.9627,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1023.9627,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL            32-486265",
      "code_information": [
        {
          "code": "3012365",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 769,
          "minimum": 262.8941,
          "maximum": 759.0765,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 558.0633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL         5820-107-530",
      "code_information": [
        {
          "code": "3012374",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 1340.201,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 990.5805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL           AT2M-L1813",
      "code_information": [
        {
          "code": "3012378",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2410,
          "minimum": 823.8943,
          "maximum": 1748.937,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1748.937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED   310.634",
      "code_information": [
        {
          "code": "3012380",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1939.7961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL CANNULATED 5.0MM",
      "code_information": [
        {
          "code": "3012381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2673,
          "minimum": 913.8048,
          "maximum": 1939.7961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1939.7961,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 1.9MM 60-19340",
      "code_information": [
        {
          "code": "3012401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1102,
          "minimum": 376.7351,
          "maximum": 799.7214,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 799.7214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL SHRT 3.2 03.010.103S",
      "code_information": [
        {
          "code": "3012406",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1666,
          "minimum": 569.5469,
          "maximum": 1209.0162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1209.0162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL 5MM     DBL-511",
      "code_information": [
        {
          "code": "3012461",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 206.8692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.8937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BALL LOOP      B0512",
      "code_information": [
        {
          "code": "3012465",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 51.1612,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 269.9604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X2.75 E1455",
      "code_information": [
        {
          "code": "3012472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.7644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 5.1X4  E1455-4",
      "code_information": [
        {
          "code": "3012473",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 116,
          "minimum": 39.6563,
          "maximum": 762.9692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.1812,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BUGBEE        BE-208",
      "code_information": [
        {
          "code": "3012474",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1372,
          "minimum": 469.0386,
          "maximum": 995.6604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 995.6604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EZ CLEAN CAUTERY TIP",
      "code_information": [
        {
          "code": "3012505",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 54,
          "minimum": 18.4607,
          "maximum": 43.3758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 39.1878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE MOD     0014AM",
      "code_information": [
        {
          "code": "3012507",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.6046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK  E2773-45",
      "code_information": [
        {
          "code": "3012520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 417,
          "minimum": 61.7271,
          "maximum": 302.6169,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 302.6169,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LIGASURE      LS1037",
      "code_information": [
        {
          "code": "3012535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2512,
          "minimum": 858.7645,
          "maximum": 1822.9584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1822.9584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-PAIRED 2CHAN 8227410",
      "code_information": [
        {
          "code": "3012585",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1545,
          "minimum": 528.1812,
          "maximum": 1121.2065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1121.2065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-RADIUS LOOP    R1010",
      "code_information": [
        {
          "code": "3012596",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 41.7075,
          "maximum": 269.9604,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 269.9604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-BLADE 6.5\\\" 0014M",
      "code_information": [
        {
          "code": "3012611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 75,
          "minimum": 25.6399,
          "maximum": 54.4275,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 54.4275,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-TEFLON 6 1/2 BLADE",
      "code_information": [
        {
          "code": "3012613",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.1532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDCAP-ROUND X-CORE    5960200",
      "code_information": [
        {
          "code": "3012635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4702,
          "minimum": 1037.1265,
          "maximum": 3412.2414,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3412.2414,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOSTITCH-173016",
      "code_information": [
        {
          "code": "3012680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2877,
          "minimum": 983.5452,
          "maximum": 2974.5789,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2087.8389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVACUATOR-UROVAC       730-125",
      "code_information": [
        {
          "code": "3012699",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 347,
          "minimum": 100.098,
          "maximum": 251.8179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 251.8179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EVAC-SAF-T-VAC         ST9000S",
      "code_information": [
        {
          "code": "3012723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 667.8761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 130.626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-GLUE             540133500",
      "code_information": [
        {
          "code": "3012805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 199.0838,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 871.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXCISOR-BIOPSY CONE",
      "code_information": [
        {
          "code": "3012815",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 122.3876,
          "maximum": 3388.3173,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 259.8006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENDER-DIALYSIS CATH  415612",
      "code_information": [
        {
          "code": "3012854",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1265,
          "minimum": 432.459,
          "maximum": 918.0105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 918.0105,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTRACTOR-TRIGEN DISP 71631320",
      "code_information": [
        {
          "code": "3012895",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 947.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LUBE-VIPERSLIDE VPR-SLD2",
      "code_information": [
        {
          "code": "3012925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 606.6852,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 606.6852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 1X6        007976",
      "code_information": [
        {
          "code": "3012991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 971,
          "minimum": 331.9508,
          "maximum": 1153.3514,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 704.6547,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FELT-TEFLON 4\\\"X4\\\"       007836",
      "code_information": [
        {
          "code": "3012993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2074,
          "minimum": 709.0277,
          "maximum": 7269.3392,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1505.1018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 200M",
      "code_information": [
        {
          "code": "3013060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2420,
          "minimum": 827.313,
          "maximum": 1756.194,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1756.194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 365M",
      "code_information": [
        {
          "code": "3013061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2010,
          "minimum": 687.1484,
          "maximum": 1473.1089,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1458.657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 550M",
      "code_information": [
        {
          "code": "3013062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2649,
          "minimum": 905.6,
          "maximum": 2081.4823,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1922.3793,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-FLEXIVA LASER 1000M",
      "code_information": [
        {
          "code": "3013063",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3743,
          "minimum": 1066.0437,
          "maximum": 2716.2951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2716.2951,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-COUDE HEYMAN   021300",
      "code_information": [
        {
          "code": "3013087",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1917,
          "minimum": 655.3549,
          "maximum": 1391.1669,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1391.1669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FOLLOWER-HEYMAN         021100",
      "code_information": [
        {
          "code": "3013090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1718,
          "minimum": 365.3577,
          "maximum": 1246.7526,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1246.7526,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERTAPER-          AR-7237-7",
      "code_information": [
        {
          "code": "3013107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 1783.4127,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 476.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 3  AR-7227-01",
      "code_information": [
        {
          "code": "3013134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 238.7553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 238.7553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBERWIRE-SUTURE 4  AR-7230-01",
      "code_information": [
        {
          "code": "3013135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 43.3758,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 261.9777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-HEPA BACTERIA 00182",
      "code_information": [
        {
          "code": "3013160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 56.6046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.6046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-PED OXYKID W/7' TUBING",
      "code_information": [
        {
          "code": "3013161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 75.6296,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 61.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FILTER-INSUFFLATION BULB",
      "code_information": [
        {
          "code": "3013164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 131.7957,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.6952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-BIOPSY DISP     1599-05",
      "code_information": [
        {
          "code": "3013203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 237,
          "minimum": 81.022,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 171.9909,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-PIRANHA 3FR     505-160",
      "code_information": [
        {
          "code": "3013317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2055,
          "minimum": 69.5125,
          "maximum": 1491.3135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1491.3135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORCEP-RADIAL JAW      000300s",
      "code_information": [
        {
          "code": "3013320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 90.7125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.7125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GEL-PROLARYN          8602M0K5",
      "code_information": [
        {
          "code": "3013462",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4034,
          "minimum": 1379.0828,
          "maximum": 52874.5441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2927.4738,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3014234",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1003,
          "minimum": 342.8905,
          "maximum": 727.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 727.8771,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-ASNIS III 6.5 DRILL",
      "code_information": [
        {
          "code": "3014235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 446.1336,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 947.0385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-AR-8737-01",
      "code_information": [
        {
          "code": "3014239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 162.5568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-VERS-FOAM 10X7.5CM",
      "code_information": [
        {
          "code": "3014272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 3372.7465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.7578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GRAFT-DBX MIX 2.5CC     058025",
      "code_information": [
        {
          "code": "3014900",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2432,
          "minimum": 831.4153,
          "maximum": 2273.3368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1764.9024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-HELI-FX            SG-64",
      "code_information": [
        {
          "code": "3016110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 107.8834,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-WIRE .035      WS-0906ST",
      "code_information": [
        {
          "code": "3016121",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 140.7858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-2MM           292.65",
      "code_information": [
        {
          "code": "3016129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 552,
          "minimum": 188.7094,
          "maximum": 400.5864,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 400.5864,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K SMOOTH TIP AGK16100",
      "code_information": [
        {
          "code": "3016134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 312,
          "minimum": 106.6618,
          "maximum": 606.7051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 226.4184,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-3.2       03.010.115",
      "code_information": [
        {
          "code": "3016135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1091,
          "minimum": 372.9746,
          "maximum": 791.7387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 791.7387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K W/OLIVE STOP",
      "code_information": [
        {
          "code": "3016136",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 263.5914,
          "maximum": 1023.237,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1023.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-SUT GABBY-FRATER SUT 013",
      "code_information": [
        {
          "code": "3016153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 695.125,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 203.196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDEWIRE-TROCAR TIP AR894301",
      "code_information": [
        {
          "code": "3016164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 299,
          "minimum": 102.2176,
          "maximum": 3161.9846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 216.9843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEAD-HALTER DISP 08143101",
      "code_information": [
        {
          "code": "3016272",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 118,
          "minimum": 40.3401,
          "maximum": 1882.3985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 85.6326,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ADHESIVE 4\\\" WHITE",
      "code_information": [
        {
          "code": "3016326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 58022.9179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOSTAT-FIBRILLAR ABSORB 1963",
      "code_information": [
        {
          "code": "3016347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1292,
          "minimum": 114.5566,
          "maximum": 937.6044,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 937.6044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOVAC-400ML LG   2550-004-10",
      "code_information": [
        {
          "code": "3016381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 1215.6346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 149.4942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-HYDRODEB     1914001",
      "code_information": [
        {
          "code": "3016387",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2186,
          "minimum": 747.3166,
          "maximum": 1586.3802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1586.3802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM SNGL PK 33508G",
      "code_information": [
        {
          "code": "3016420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 194,
          "minimum": 66.3218,
          "maximum": 2308.9272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 140.7858,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-BLUNT 12MM DOUBLE  3384-4",
      "code_information": [
        {
          "code": "3016425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 434,
          "minimum": 148.3693,
          "maximum": 1679.422,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 2X4 2082",
      "code_information": [
        {
          "code": "3016450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 331.9508,
          "maximum": 704.6547,
          "payers_information": [
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              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-SNOW 4X4 2083",
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        {
          "code": "3016451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 429.0404,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 910.7535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOOK-J CAUTERY     60-5272-232",
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        {
          "code": "3016500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 93.671,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMMOBILIZER-ULTRASLING III XLG",
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        {
          "code": "3017486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 147.6856,
          "maximum": 347.5625,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUTTLE-ACCU PASS SUTURE 70DEG",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 456.0477,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-EVERGRIP LF  EVERGRIP61",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 110.0805,
          "maximum": 2039.2187,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FDG",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGL",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-BIPOLAR FORCEP 28164FGD",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 1029.0132,
          "maximum": 2184.357,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-PEELAWAY 16F",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 446.3055,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-TAUT 9FR 3 1/2 PI93",
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 130.2505,
          "maximum": 276.4917,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2MM 500373",
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        {
          "code": "3020202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 242.3822,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-CASPER DISTRACTOR FF904SB",
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        {
          "code": "3020203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1060,
          "minimum": 362.3768,
          "maximum": 769.242,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 769.242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 17L 96550",
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        {
          "code": "3020800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 176.0604,
          "maximum": 2737.6803,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 373.7355,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXPANDER-I RING PUPIL 587000",
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        {
          "code": "3020804",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 427.6729,
          "maximum": 907.8507,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 907.8507,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HARNESS-CERVICAL VISULIZATION",
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        {
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 10 GAUG 03.804.522S",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "maximum": 623.3763,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 623.3763,
              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SCOPE WARMER TM500",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 34.8702,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-VENTI SCAN IV DISP 177-092",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
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          "minimum": 154.1811,
          "maximum": 3042.9792,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESSORY 700     72401850",
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        {
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ASSEMBLY ANTI-COAG  CSP208",
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        {
          "code": "3020850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 76.5777,
          "maximum": 2343.4054,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DILATOR NVM5       2029950",
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        {
          "code": "3020915",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 3479.7315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-19",
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        {
          "code": "3020920",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 465.6199,
          "maximum": 1248.4445,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 988.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC      96530-21",
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        {
          "code": "3020922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 497.7095,
          "maximum": 1629.1965,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-FEMORAL PERC     96530-017",
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        {
          "code": "3020928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 402.3749,
          "maximum": 2227.1805,
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            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 854.1489,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-IV MAXCESS         3240060",
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        {
          "code": "3020969",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PLEURX PT STARTER  50-0071",
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        {
          "code": "3021029",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 782.5287,
          "maximum": 2001.4039,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1661.1273,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHUNT NONINVASIVE  9733605",
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        {
          "code": "3021032",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3599,
          "minimum": 895.321,
          "maximum": 2611.7943,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2611.7943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 4ML 1501262",
      "code_information": [
        {
          "code": "3021034",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1610,
          "minimum": 264.7036,
          "maximum": 1168.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1168.377,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TORQUE WRENCH&BOOT 3550-80",
      "code_information": [
        {
          "code": "3021046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 476,
          "minimum": 162.7277,
          "maximum": 1362.445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 345.4332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PERITONEAL DIALYSIS 278006",
      "code_information": [
        {
          "code": "3021065",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1150,
          "minimum": 96.2053,
          "maximum": 834.555,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 834.555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SHOULDER CANNULA 5CM  9718",
      "code_information": [
        {
          "code": "3021080",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 173,
          "minimum": 59.1426,
          "maximum": 974.8433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 125.5461,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-URO MAX HI PRESURE 225-136",
      "code_information": [
        {
          "code": "3021090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1753,
          "minimum": 599.2891,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1272.1521,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXTRACTION GTG14",
      "code_information": [
        {
          "code": "3021113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4570,
          "minimum": 1562.3224,
          "maximum": 3316.449,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3316.449,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SCREW-BONE 2.3X12MM 663812",
      "code_information": [
        {
          "code": "3021130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 951,
          "minimum": 67.2881,
          "maximum": 690.1407,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 690.1407,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE,SLIT 2.4MM 45 DEGREE",
      "code_information": [
        {
          "code": "3021161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 263,
          "minimum": 89.9105,
          "maximum": 1114.4244,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 190.8591,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-GRAFT ACL 10MM    232110",
      "code_information": [
        {
          "code": "3021173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2004,
          "minimum": 271.3768,
          "maximum": 1454.3028,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1454.3028,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SLIT CLEAR CUT 2.4",
      "code_information": [
        {
          "code": "3021199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 488,
          "minimum": 58.9466,
          "maximum": 354.1416,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 354.1416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDE PORT 1.1    78-2010",
      "code_information": [
        {
          "code": "3021203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 937.5846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-TUIP             880-217",
      "code_information": [
        {
          "code": "3021220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 749,
          "minimum": 256.0568,
          "maximum": 667.8761,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 543.5493,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE ALL AR-4000Ss",
      "code_information": [
        {
          "code": "3021225",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1201,
          "minimum": 410.5797,
          "maximum": 871.5657,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 871.5657,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LASSO-SUTURE         AR-4068's",
      "code_information": [
        {
          "code": "3021227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 4811.9333,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1060.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KNIFE-SIDEPORT SAFETY 1.0MM",
      "code_information": [
        {
          "code": "3021241",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 324,
          "minimum": 110.7642,
          "maximum": 11292.7227,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.1268,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINER-SZ25/36MM RL 12-105995",
      "code_information": [
        {
          "code": "3021635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4400,
          "minimum": 1504.2054,
          "maximum": 8241.402,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3193.08,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LIGASURE-IMPACT         LF4318",
      "code_information": [
        {
          "code": "3021733",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2708,
          "minimum": 145.1421,
          "maximum": 1965.1956,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1965.1956,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LINE-DRAINAGE LOCKABLE 50-7245",
      "code_information": [
        {
          "code": "3021737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 189.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-CUTTING 26FR      880-214",
      "code_information": [
        {
          "code": "3021821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 694,
          "minimum": 134.0201,
          "maximum": 503.6358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 503.6358,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-DISPOSA ALL",
      "code_information": [
        {
          "code": "3021826",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 241,
          "minimum": 82.3894,
          "maximum": 2666.4995,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 174.8937,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-ELECTRODE 24FR   WA22037C",
      "code_information": [
        {
          "code": "3021880",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1483,
          "minimum": 326.4307,
          "maximum": 1076.2131,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1076.2131,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "LOOP-WIRE SNARE 8-14515",
      "code_information": [
        {
          "code": "3021881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 1048.8046,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 425.9859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-MS SSEP NEEDLE  8050315",
      "code_information": [
        {
          "code": "3022945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5246,
          "minimum": 1793.4231,
          "maximum": 3807.0222,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3807.0222,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE EMG 8050015",
      "code_information": [
        {
          "code": "3022950",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MODULE-NVM5 NEEDLE MEP/EMG",
      "code_information": [
        {
          "code": "3022955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5077,
          "minimum": 1735.6479,
          "maximum": 4022.8274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3684.3789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SINGLE PORT PAL 240LS",
      "code_information": [
        {
          "code": "3023177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 796,
          "minimum": 272.1244,
          "maximum": 4022.8274,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 577.6572,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY STEALTH  9733068",
      "code_information": [
        {
          "code": "3027284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4784,
          "minimum": 117.8932,
          "maximum": 3471.7488,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3471.7488,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY TRU CUT 2N2700s",
      "code_information": [
        {
          "code": "3027285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 212,
          "minimum": 72.4754,
          "maximum": 153.8484,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 153.8484,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-BIOPSY CUT      4418-16",
      "code_information": [
        {
          "code": "3027295",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 413.7384,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.6647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DEFLUX 23GX3.7FX350mm",
      "code_information": [
        {
          "code": "3027296",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 744,
          "minimum": 254.3475,
          "maximum": 539.9208,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 539.9208,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-DISP INSUF      S100000",
      "code_information": [
        {
          "code": "3027310",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 482,
          "minimum": 45.0441,
          "maximum": 349.7874,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ELECTRODE COATD E1465-6",
      "code_information": [
        {
          "code": "3027313",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 399.8359,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.7817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ENDOPATH INSUFF   PN120",
      "code_information": [
        {
          "code": "3027315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 719,
          "minimum": 245.8008,
          "maximum": 521.7783,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 521.7783,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-EPIDURAL       105-1314",
      "code_information": [
        {
          "code": "3027318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 88.4199,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 519.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CHIBA 22-20      G00013",
      "code_information": [
        {
          "code": "3027330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 230.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 115.3863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-FORAMEN 20G      041829",
      "code_information": [
        {
          "code": "3027344",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 415,
          "minimum": 141.8739,
          "maximum": 301.1655,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 301.1655,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-JAMSHIDI 11-6 DJ6011X",
      "code_information": [
        {
          "code": "3027346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 292,
          "minimum": 99.8245,
          "maximum": 216.879,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 211.9044,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR        1650050",
      "code_information": [
        {
          "code": "3027347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 390,
          "minimum": 125.6786,
          "maximum": 283.023,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 283.023,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INSULATED EDGE   E1465B",
      "code_information": [
        {
          "code": "3027368",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 226,
          "minimum": 77.2615,
          "maximum": 719.5934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.0082,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TR-CRON 2-0 STR W/10 SW",
      "code_information": [
        {
          "code": "3027402",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 437,
          "minimum": 149.3949,
          "maximum": 348.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 317.1309,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-INJECTOR W/SHEATH",
      "code_information": [
        {
          "code": "3027403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 626,
          "minimum": 214.0074,
          "maximum": 454.2882,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 454.2882,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OPUS SPEEDSTITCH",
      "code_information": [
        {
          "code": "3027425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 397,
          "minimum": 135.7203,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 288.1029,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-OCTRODE 6\\\"         1116",
      "code_information": [
        {
          "code": "3027430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 519.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODESSECTION   N103A",
      "code_information": [
        {
          "code": "3027433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 690,
          "minimum": 235.8868,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 500.733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SCORPION      AR-13991N",
      "code_information": [
        {
          "code": "3027443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 440.9873,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1060.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-SIDEKICK 21GA 14.6\\\"",
      "code_information": [
        {
          "code": "3027445",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 793,
          "minimum": 207.4253,
          "maximum": 575.4801,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 575.4801,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-MICRODISSECTION   E1xxx",
      "code_information": [
        {
          "code": "3027520",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 795,
          "minimum": 45.0441,
          "maximum": 576.9315,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 576.9315,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-W/BASEPLATE BSDN-18-7.0",
      "code_information": [
        {
          "code": "3027587",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 722.3739,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.7817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP 5MM  VS101005",
      "code_information": [
        {
          "code": "3027591",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1299,
          "minimum": 444.0825,
          "maximum": 942.6843,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 942.6843,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-VERSASTEP 14GA VS150000",
      "code_information": [
        {
          "code": "3027593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 600,
          "minimum": 205.1189,
          "maximum": 680.6664,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 435.42,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-TROCAR 12MM VS101000s",
      "code_information": [
        {
          "code": "3027595",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1224,
          "minimum": 418.4426,
          "maximum": 888.2568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 888.2568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-WILSON PENILE IMPLANT",
      "code_information": [
        {
          "code": "3029175",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2504,
          "minimum": 856.0296,
          "maximum": 1817.1528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1817.1528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-FENWAL TRANSFER 4R2014",
      "code_information": [
        {
          "code": "3029199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 373.1431,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 74.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-EXTREMITY      DYNJ31779F",
      "code_information": [
        {
          "code": "3029200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 671,
          "minimum": 75.6296,
          "maximum": 486.9447,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 486.9447,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-MAGNETIC DRAPE    31140562",
      "code_information": [
        {
          "code": "3029201",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 136,
          "minimum": 46.4936,
          "maximum": 1966.3696,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 98.6952,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SPY ELITE VIAL     LC3001",
      "code_information": [
        {
          "code": "3029202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3536,
          "minimum": 1208.8341,
          "maximum": 2566.0752,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2566.0752,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-SENSA TRAC M8275057/10",
      "code_information": [
        {
          "code": "3029214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 196.6647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.6647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-PERFUSION CUSTOM  CK0226R",
      "code_information": [
        {
          "code": "3029252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3994,
          "minimum": 145.1421,
          "maximum": 2898.4458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2898.4458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SHOULDER ARTHROSCOP 29367",
      "code_information": [
        {
          "code": "3029266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 261,
          "minimum": 89.2267,
          "maximum": 189.4077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 189.4077,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-SINUS KENNEDY      400422",
      "code_information": [
        {
          "code": "3029267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 656.198,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.9497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL 4.5CM     440400",
      "code_information": [
        {
          "code": "3029278",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 200.2932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAK-CONFIDENCE PLUS",
      "code_information": [
        {
          "code": "3029292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-HAND DYNJ52365",
      "code_information": [
        {
          "code": "3029301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 636,
          "minimum": 217.4261,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 461.5452,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-VITRECTOMY CENTURION",
      "code_information": [
        {
          "code": "3029308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1137.1719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-MALLEABLE CATH  82-151x",
      "code_information": [
        {
          "code": "3029345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1307,
          "minimum": 446.8174,
          "maximum": 948.4899,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 948.4899,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SMART STITCH PERFECT",
      "code_information": [
        {
          "code": "3029347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 917,
          "minimum": 265.8158,
          "maximum": 665.4669,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 665.4669,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-SUTURE           032401",
      "code_information": [
        {
          "code": "3029348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 396.4993,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 346.8846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-HEMA KNITTED   HGK75/75P",
      "code_information": [
        {
          "code": "3029426",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1254,
          "minimum": 428.6985,
          "maximum": 7405.5837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 910.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PATCH-ACTIVA 2.5 INTELLIDOSE",
      "code_information": [
        {
          "code": "3029528",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.6779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PERFORATOR-DISPOSABLE  26-1221",
      "code_information": [
        {
          "code": "3029529",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 915.5141,
          "maximum": 2058.1261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1943.4246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORIENTATION 2307-71-000",
      "code_information": [
        {
          "code": "3029762",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 994,
          "minimum": 339.8137,
          "maximum": 721.3458,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 721.3458,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-NAVIGATION 6007-003-150",
      "code_information": [
        {
          "code": "3029767",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 150.7031,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 678.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ARM ELEVATION 79-90500",
      "code_information": [
        {
          "code": "3029771",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 271,
          "minimum": 92.6454,
          "maximum": 520.5096,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 196.6647,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-KNEE PROCEDURE TRACK 10712",
      "code_information": [
        {
          "code": "3029811",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 180.7325,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 988.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-DEMAYO LEG 110550",
      "code_information": [
        {
          "code": "3029813",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 325,
          "minimum": 111.1061,
          "maximum": 533.856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 235.8525,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BREAKAWAY GUIDE 2.5MM",
      "code_information": [
        {
          "code": "3029840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2605,
          "minimum": 603.9246,
          "maximum": 1890.4485,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1890.4485,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144110",
      "code_information": [
        {
          "code": "3029841",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1086,
          "minimum": 371.2652,
          "maximum": 788.1102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 788.1102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-DHS GUIDE          900.723",
      "code_information": [
        {
          "code": "3029855",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 658,
          "minimum": 224.9471,
          "maximum": 551.6512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 477.5106,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-POSITIONING EZ CLIP 2MM",
      "code_information": [
        {
          "code": "3029858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1123,
          "minimum": 383.9142,
          "maximum": 1046.0241,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 814.9611,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-FLUTED HEADLESS 7650-2038A",
      "code_information": [
        {
          "code": "3029885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1881,
          "minimum": 616.7149,
          "maximum": 1365.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1365.0417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE              357.399",
      "code_information": [
        {
          "code": "3029929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1109,
          "minimum": 379.1281,
          "maximum": 3924.9538,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 804.8013,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PINS-GUIDE 7.3         900.726",
      "code_information": [
        {
          "code": "3030050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 943,
          "minimum": 207.4253,
          "maximum": 684.3351,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 684.3351,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-HUBER 20G X 1\\\"",
      "code_information": [
        {
          "code": "3033301",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 48,
          "minimum": 16.4095,
          "maximum": 34.8336,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 34.8336,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-FOLEY 16FR 10ML",
      "code_information": [
        {
          "code": "3033303",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-F SCREWS 45-80040",
      "code_information": [
        {
          "code": "3033883",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1582.6606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1060.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PLEDGET-LARGE SOFT       PCP40",
      "code_information": [
        {
          "code": "3033952",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.5247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POINTER-TRACER         9733423",
      "code_information": [
        {
          "code": "3034140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3396,
          "minimum": 175.7276,
          "maximum": 2464.4772,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2464.4772,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-BIOPSY             AUR-BP",
      "code_information": [
        {
          "code": "3034190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 316,
          "minimum": 108.0293,
          "maximum": 2196.0389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 229.3212,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-GEL HAND            C8XX2",
      "code_information": [
        {
          "code": "3034194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2865.7893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOCATCH-II W/POUCH ALL 173's",
      "code_information": [
        {
          "code": "3034302",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2140,
          "minimum": 497.7095,
          "maximum": 1552.998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1552.998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-GOLD ENTERAL 7FR 350CM",
      "code_information": [
        {
          "code": "3034510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1137.1719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-NEUROVISION M5   2012021",
      "code_information": [
        {
          "code": "3034522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2309,
          "minimum": 592.2465,
          "maximum": 1675.6413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1675.6413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROBE-FIAPC 2.3MM 6.9FR 300CM",
      "code_information": [
        {
          "code": "3034891",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 573.6492,
          "maximum": 8367.0806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1217.7246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROTECTOR-WOUND GELPOINT CNGL2",
      "code_information": [
        {
          "code": "3038330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 1446.4302,
          "maximum": 19421.7925,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3070.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUMP-PAIN ONQ 400ML    PM028-A",
      "code_information": [
        {
          "code": "3038635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1884,
          "minimum": 644.0734,
          "maximum": 3289.8876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1367.2188,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUSHER-KNOT 2-0 FIBERWIRE",
      "code_information": [
        {
          "code": "3038667",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1305,
          "minimum": 99.5419,
          "maximum": 947.0385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 947.0385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PUNCH-DEKNATEL 4.4      MDP-44",
      "code_information": [
        {
          "code": "3038930",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 398,
          "minimum": 136.0622,
          "maximum": 525.5145,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 288.8286,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ECHELON GREEN    ECR45G",
      "code_information": [
        {
          "code": "3039881",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1406,
          "minimum": 207.4253,
          "maximum": 1020.3342,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1020.3342,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO LINEAR       TR35B",
      "code_information": [
        {
          "code": "3039888",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 838,
          "minimum": 47.2685,
          "maximum": 608.1366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 608.1366,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "REDUCER-TUBING         RF10210",
      "code_information": [
        {
          "code": "3039889",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 80.0784,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 61.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W564",
      "code_information": [
        {
          "code": "3039894",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 104.5008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 104.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BALL-JURGAN PIN           W332",
      "code_information": [
        {
          "code": "3039896",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 239.6791,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 104.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM GREEN        XR30G",
      "code_information": [
        {
          "code": "3039899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 431,
          "minimum": 147.3438,
          "maximum": 312.7767,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 312.7767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH       170056",
      "code_information": [
        {
          "code": "3039902",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 676.2176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 625.5534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-VASCULAR/THIN     TR45W",
      "code_information": [
        {
          "code": "3039909",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 239.6791,
          "maximum": 882.4512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 882.4512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-30MM              XR30B",
      "code_information": [
        {
          "code": "3039911",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 431,
          "minimum": 147.3438,
          "maximum": 676.2176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 312.7767,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STANDARD BLUE     6R45B",
      "code_information": [
        {
          "code": "3039912",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1216,
          "minimum": 415.7077,
          "maximum": 944.8139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 882.4512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40B",
      "code_information": [
        {
          "code": "3039913",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1699,
          "minimum": 277.4939,
          "maximum": 1232.9643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1232.9643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD- STAPLE TCR-55",
      "code_information": [
        {
          "code": "3039914",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 499,
          "minimum": 170.5906,
          "maximum": 456.002,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 362.1243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-LINEAR CUTTER    TCR-75",
      "code_information": [
        {
          "code": "3039916",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 820,
          "minimum": 280.3292,
          "maximum": 944.8139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 595.074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-STAPLE CONTOUR    CR40G",
      "code_information": [
        {
          "code": "3039917",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1699,
          "minimum": 580.8284,
          "maximum": 1232.9643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1232.9643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER    TCT75",
      "code_information": [
        {
          "code": "3039918",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1465,
          "minimum": 285.8354,
          "maximum": 1063.1505,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1063.1505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDO GIA 30/3.5  030452",
      "code_information": [
        {
          "code": "3039932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 704.5835,
          "maximum": 1495.6677,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-CARIOTOMY        205",
      "code_information": [
        {
          "code": "3039975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 465,
          "minimum": 158.9672,
          "maximum": 6833.3568,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 337.4505,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-DISP FILTRA 04259",
      "code_information": [
        {
          "code": "3039981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 585,
          "minimum": 199.9909,
          "maximum": 7440.618,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 424.5345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RESERVOIR-OMMAYA    NL850-121x",
      "code_information": [
        {
          "code": "3040439",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3043,
          "minimum": 170.1666,
          "maximum": 2208.3051,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2208.3051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-C-SECTION DISP G6314",
      "code_information": [
        {
          "code": "3040500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 281.6966,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND          C8404",
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        {
          "code": "3040501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 281.6966,
          "maximum": 1489.2358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 597.9768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEXOR TENDON",
      "code_information": [
        {
          "code": "3040509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2678,
          "minimum": 600.588,
          "maximum": 1943.4246,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1943.4246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-LONESTAR        3304",
      "code_information": [
        {
          "code": "3040511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1080,
          "minimum": 369.214,
          "maximum": 895.8771,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 783.756,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-ORTHO ALEXIS   HR004",
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        {
          "code": "3040513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1611,
          "minimum": 310.3038,
          "maximum": 1169.1027,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1169.1027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE        013593",
      "code_information": [
        {
          "code": "3040518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 558,
          "minimum": 190.7606,
          "maximum": 761.857,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 404.9406,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-SURGICAL RING   3715",
      "code_information": [
        {
          "code": "3040521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1370,
          "minimum": 415.4067,
          "maximum": 994.209,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 994.209,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-LOOPED 3 PRONG  5030",
      "code_information": [
        {
          "code": "3040525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 542.0979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND LG       C8303",
      "code_information": [
        {
          "code": "3040527",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 657,
          "minimum": 224.6052,
          "maximum": 476.7849,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 476.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND MEDIUM   C8302",
      "code_information": [
        {
          "code": "3040530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 458.2264,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 312.051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XL       C8304",
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        {
          "code": "3040532",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 824,
          "minimum": 239.123,
          "maximum": 597.9768,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 597.9768,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND SMALL    C8301",
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        {
          "code": "3040533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 312.051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 312.051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-WOUND XSMALL   C8312",
      "code_information": [
        {
          "code": "3040534",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 430,
          "minimum": 147.0019,
          "maximum": 726.8227,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 312.051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-MALYUGIN ALL SZS MAL-000x",
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        {
          "code": "3040661",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1565,
          "minimum": 535.0185,
          "maximum": 2728.2266,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1135.7205,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COUNTERSINK-1.7MM 2.8 CANN DRI",
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        {
          "code": "3040704",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 585.2726,
          "maximum": 1301.8301,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 1242.3984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SABRE-2.0X7          AR-7200S",
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        {
          "code": "3044850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 282.7222,
          "maximum": 1548.7385,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 600.1539,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS 2.3 BIPOLAR",
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          "code": "3044897",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 952.0936,
          "maximum": 2021.0745,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2021.0745,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-AQUAMANTYS MALLEABLE BI",
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        {
          "code": "3044899",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 336.9966,
          "maximum": 2333.1255,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-IRRIGATION ANSPACH 111613",
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        },
        {
          "code": "0270",
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        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 255.806,
          "maximum": 701.0262,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68HP ALL",
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          "code": "3049715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 142.8995,
          "maximum": 303.3426,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 303.3426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-TRI PORT III PAL 303LS",
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        {
          "code": "3050004",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 224.6052,
          "maximum": 580.0123,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 476.7849,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 4.0X170 144170",
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        {
          "code": "3050009",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 323.0623,
          "maximum": 1754.4955,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 685.7865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-CELLEBRITY CYTOLOGY",
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        {
          "code": "3050015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 79.9964,
          "maximum": 4265.287,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 169.8138,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-CAPTIVATIR SM DISP 13MM",
      "code_information": [
        {
          "code": "3055843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 833.5939,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.9629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TISSEEL FROZEN 2ML 1506078",
      "code_information": [
        {
          "code": "3055845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1499,
          "minimum": 512.4554,
          "maximum": 39817.3161,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1087.8243,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-HELICAL ALL SZS 456.30Xs",
      "code_information": [
        {
          "code": "3055898",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3677,
          "minimum": 1233.9859,
          "maximum": 2668.3989,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2668.3989,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-MISTY NEB W/FILTER",
      "code_information": [
        {
          "code": "3058511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 607.2612,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.6219,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-HELIOCOIDAL RASP 3.2MM",
      "code_information": [
        {
          "code": "3058512",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1092,
          "minimum": 373.3164,
          "maximum": 995.9751,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 792.4644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-BONE MILL DISP",
      "code_information": [
        {
          "code": "3058513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1791,
          "minimum": 262.4792,
          "maximum": 1299.7287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1299.7287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CASSETTE-CORE IRRIGATION",
      "code_information": [
        {
          "code": "3058514",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 472,
          "minimum": 161.3602,
          "maximum": 605.5929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 342.5304,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 2.3MM",
      "code_information": [
        {
          "code": "3058515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1089,
          "minimum": 372.2908,
          "maximum": 790.2873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 790.2873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-SOFT TOUCH RND FLUTED ALL",
      "code_information": [
        {
          "code": "3058516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 990.5805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND ALL SIZES",
      "code_information": [
        {
          "code": "3058517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 436.5614,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 926.7189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND COURSE ALL",
      "code_information": [
        {
          "code": "3058518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 990.5805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ROUTER-TAPERED 3.0MM",
      "code_information": [
        {
          "code": "3058521",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1089,
          "minimum": 372.2908,
          "maximum": 790.2873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 790.2873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DISC-CUTTING DIAMOND 25.4X0.8",
      "code_information": [
        {
          "code": "3058522",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1042,
          "minimum": 356.2232,
          "maximum": 862.5111,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 756.1794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5 310.23S",
      "code_information": [
        {
          "code": "3058526",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1551,
          "minimum": 530.2324,
          "maximum": 1125.5607,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1125.5607,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 02.7 CSS-072-27",
      "code_information": [
        {
          "code": "3058530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1347,
          "minimum": 460.492,
          "maximum": 977.5179,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 977.5179,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X110 143110",
      "code_information": [
        {
          "code": "3058543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 683,
          "minimum": 233.4937,
          "maximum": 495.6531,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 495.6531,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-EPIDURAL 117\\\" INF 1633902",
      "code_information": [
        {
          "code": "3058611",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 689.0079,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 112.4835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-CONFIDENCE 10X5",
      "code_information": [
        {
          "code": "3058612",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1239,
          "minimum": 423.5706,
          "maximum": 1157.2441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 899.1423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-FLOW 50 COBLATION",
      "code_information": [
        {
          "code": "3058620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1833,
          "minimum": 626.6383,
          "maximum": 1330.2081,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1330.2081,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-ACCOMINIZER 4.0",
      "code_information": [
        {
          "code": "3058623",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 531.6316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 320.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-STONCUTTER 5.5 7205331",
      "code_information": [
        {
          "code": "3058624",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 956,
          "minimum": 279.1622,
          "maximum": 693.7692,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 693.7692,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-GO FLOW INFLOW T0449-01",
      "code_information": [
        {
          "code": "3058625",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 364.3014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4.0 1864G",
      "code_information": [
        {
          "code": "3058639",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 14474.7269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-OVAL FLEX MED 27MM",
      "code_information": [
        {
          "code": "3058643",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 523.2901,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.5807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NET-RETRIEVAL 30MM DGN-538-5",
      "code_information": [
        {
          "code": "3058644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 941,
          "minimum": 321.6948,
          "maximum": 682.8837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 682.8837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-ROUND 2.0MM 5820-010-020",
      "code_information": [
        {
          "code": "3058655",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1105,
          "minimum": 377.7607,
          "maximum": 8499.9885,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 801.8985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ARTHREX ANGEL BMC",
      "code_information": [
        {
          "code": "3058674",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 870.8526,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDO FEEDING 12FR X 60”",
      "code_information": [
        {
          "code": "3058693",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 378,
          "minimum": 129.2249,
          "maximum": 274.3146,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 274.3146,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-MINI 4.0 283459",
      "code_information": [
        {
          "code": "3058696",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1275,
          "minimum": 435.8777,
          "maximum": 925.2675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 925.2675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MINI 3.5 FULL RADIUS",
      "code_information": [
        {
          "code": "3058697",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1275,
          "minimum": 435.8777,
          "maximum": 925.2675,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 925.2675,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 018 14MMX34CM",
      "code_information": [
        {
          "code": "3058707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4231,
          "minimum": 877.5258,
          "maximum": 3070.4367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3070.4367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLAMP-5 HOLE 4922-2-240",
      "code_information": [
        {
          "code": "3058716",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1082,
          "minimum": 369.8978,
          "maximum": 785.2074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 785.2074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ANOSCOPE-BEVELED DISP 103X18M",
      "code_information": [
        {
          "code": "3058720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 16442.2087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-EXPEL NEPHR I/E 8.3/22",
      "code_information": [
        {
          "code": "3058729",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1262,
          "minimum": 431.4335,
          "maximum": 915.8334,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 915.8334,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTRODUCER-ENDOTRACH 15FR 71C",
      "code_information": [
        {
          "code": "3058737",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 96,
          "minimum": 32.819,
          "maximum": 7838.7856,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 69.6672,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACKER-VPAD 2 INS-0050",
      "code_information": [
        {
          "code": "3058749",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2207,
          "minimum": 754.4957,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1601.6199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-ALWAYS ON TIP INS-0352",
      "code_information": [
        {
          "code": "3058751",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2117.5926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-19 GA ANSO INS-0382",
      "code_information": [
        {
          "code": "3058752",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2117.5926,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2117.5926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-21 GA ANSO INS 0392",
      "code_information": [
        {
          "code": "3058753",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2918,
          "minimum": 997.5617,
          "maximum": 2321.7175,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2117.5926,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-22 GA NITINOL INS-5410",
      "code_information": [
        {
          "code": "3058754",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4175,
          "minimum": 1227.3127,
          "maximum": 3029.7975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3029.7975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 8MMX24CM",
      "code_information": [
        {
          "code": "3058757",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 6MMX17CM",
      "code_information": [
        {
          "code": "3058758",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 8523.9008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE DISTRACTOR DISP",
      "code_information": [
        {
          "code": "3058766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 192.8118,
          "maximum": 935.3602,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 409.2948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR CX 035 4MMX7CM",
      "code_information": [
        {
          "code": "3058776",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MM X xCM",
      "code_information": [
        {
          "code": "3058777",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 32205.4193,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.0 AR 8943-16",
      "code_information": [
        {
          "code": "3058786",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1013,
          "minimum": 346.3091,
          "maximum": 2388.4495,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 735.1341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPIN EWC BIOPSY GUIDE",
      "code_information": [
        {
          "code": "3058788",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3127,
          "minimum": 1069.0114,
          "maximum": 3022.4035,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2269.2639,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "Q-FIX-DISP SHOULDER 1.8MM",
      "code_information": [
        {
          "code": "3058805",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1659,
          "minimum": 567.1538,
          "maximum": 1455.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1203.9363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENTRAINER-AIR RT008",
      "code_information": [
        {
          "code": "3058809",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 725.7105,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 5.0 5050",
      "code_information": [
        {
          "code": "3058819",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58043,
          "minimum": 19842.8621,
          "maximum": 42121.8051,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42121.8051,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BEQ-HLS ADVANCED 7.0 7050",
      "code_information": [
        {
          "code": "3058820",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60044,
          "minimum": 99.5419,
          "maximum": 43573.9308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43573.9308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0 BV-1 M8709",
      "code_information": [
        {
          "code": "3058836",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 255.3731,
          "maximum": 1119.9854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 542.0979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 6MM X xxCM",
      "code_information": [
        {
          "code": "3058840",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 2MMXxxCM",
      "code_information": [
        {
          "code": "3058843",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4220,
          "minimum": 1442.6697,
          "maximum": 3062.454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3062.454,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX20CM",
      "code_information": [
        {
          "code": "3058844",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5064,
          "minimum": 1731.2037,
          "maximum": 3674.9448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3674.9448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 018 xxMMX30CM",
      "code_information": [
        {
          "code": "3058845",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5591,
          "minimum": 1911.3664,
          "maximum": 4057.3887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4057.3887,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 CX ALL",
      "code_information": [
        {
          "code": "3058847",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 10038.1611,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-HEATED AIRVO 900PT501",
      "code_information": [
        {
          "code": "3058860",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 181.8447,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 519.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-AIRVO SM OPT942",
      "code_information": [
        {
          "code": "3058861",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 237.3039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.3039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-MCGRATH 350-013-000 SZ4",
      "code_information": [
        {
          "code": "3058864",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 112.4835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CAP-HEALING W/PLUG 30MM 95084",
      "code_information": [
        {
          "code": "3058868",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 42.8197,
          "maximum": 156.7512,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 156.7512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ORAL ENDO MURPHY 4.5MM",
      "code_information": [
        {
          "code": "3058875",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.8616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COLLAR-CONTOUR CERVICAL 13-15",
      "code_information": [
        {
          "code": "3058876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 61.7271,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BELT-RIB UNIVERSAL 8” MALE",
      "code_information": [
        {
          "code": "3058877",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 111,
          "minimum": 37.2587,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 80.5527,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3.0 1893G",
      "code_information": [
        {
          "code": "3058878",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 66.1759,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.6219,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "COIL-AZUR 035 4MMX15CM",
      "code_information": [
        {
          "code": "3058884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 129.5713,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-NASAL SLIM MED",
      "code_information": [
        {
          "code": "3058885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 233,
          "minimum": 79.6545,
          "maximum": 216.3229,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 169.0881,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-SYSTEM UA2007",
      "code_information": [
        {
          "code": "3058887",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 162,
          "minimum": 55.3821,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 117.5634,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-WATER SUCTION BIOPSY VALVE",
      "code_information": [
        {
          "code": "3058903",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 130,
          "minimum": 44.4424,
          "maximum": 70265.4594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 94.341,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FIBER-ACCUSTAT 125NM S 801015",
      "code_information": [
        {
          "code": "3058929",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5081,
          "minimum": 280.8305,
          "maximum": 3687.2817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3687.2817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-MIDLINE 5FR BIO FLO",
      "code_information": [
        {
          "code": "3058932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 6424.6233,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.6308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 1.4X27MM",
      "code_information": [
        {
          "code": "3058955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3358,
          "minimum": 1147.9822,
          "maximum": 12836.4563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2436.9006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEMOCON,CAPIOX HPH-1000",
      "code_information": [
        {
          "code": "3058981",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 291.2689,
          "maximum": 3058.55,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 618.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENDOBLADE GASTRO",
      "code_information": [
        {
          "code": "3058983",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5049,
          "minimum": 522.734,
          "maximum": 3664.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3664.0593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-ORTHOLOCK 3X110MM EX",
      "code_information": [
        {
          "code": "3058990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 319.6436,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 678.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-GUIDE 3.2X 343MM",
      "code_information": [
        {
          "code": "3058991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1159,
          "minimum": 396.2214,
          "maximum": 841.0863,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 841.0863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0 Y935H",
      "code_information": [
        {
          "code": "3059006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 93,
          "minimum": 31.7934,
          "maximum": 9709.506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 67.4901,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL RADIUS 2.0X40X91MM",
      "code_information": [
        {
          "code": "3059015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1036,
          "minimum": 354.172,
          "maximum": 751.8252,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 751.8252,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-GENESYS HTA M006580211",
      "code_information": [
        {
          "code": "3059026",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 6769,
          "minimum": 870.8526,
          "maximum": 4912.2633,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4912.2633,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-CLEANING STICK 900PT602",
      "code_information": [
        {
          "code": "3059061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 93.4248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-QUADFUSE 9” EXT SMALLBORE",
      "code_information": [
        {
          "code": "3059062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 1661.0707,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 121.9176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED OPT316",
      "code_information": [
        {
          "code": "3059066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 522,
          "minimum": 178.4535,
          "maximum": 401.5042,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 378.8154,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "POSITIONER-HEADREST SOFTOUCH",
      "code_information": [
        {
          "code": "3059127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 125,
          "minimum": 42.7331,
          "maximum": 12074.0432,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 90.7125,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-ESOPHYX TIF R2007",
      "code_information": [
        {
          "code": "3059129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21712,
          "minimum": 1866.2716,
          "maximum": 15756.3984,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15756.3984,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-FILTER CONNECT PT-5558-F",
      "code_information": [
        {
          "code": "3059131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 72,
          "minimum": 24.6143,
          "maximum": 722.93,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 52.2504,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL TWIST 3.5X195 700353",
      "code_information": [
        {
          "code": "3059137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1228,
          "minimum": 419.81,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 891.1596,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEEDLE-ACQUIRE EUS FND",
      "code_information": [
        {
          "code": "3059156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2651,
          "minimum": 497.7095,
          "maximum": 1923.8307,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1923.8307,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-SPEED DRILL 2.0MM BIT",
      "code_information": [
        {
          "code": "3059170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2114,
          "minimum": 279.1622,
          "maximum": 1534.1298,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1534.1298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUIDE-IMPLANT SIZING SG - x",
      "code_information": [
        {
          "code": "3059171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 6595.346,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 364.3014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DIALYZER-HIGH FLUX 1.6 720DH16",
      "code_information": [
        {
          "code": "3059177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 859.1745,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 122.6433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ULTRAPERC FULL 100/573/000",
      "code_information": [
        {
          "code": "3059178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1545,
          "minimum": 30.5855,
          "maximum": 1121.2065,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1121.2065,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT MED",
      "code_information": [
        {
          "code": "3059179",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 2180.4681,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 39.9135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ENVEO PRO LOADING",
      "code_information": [
        {
          "code": "3059185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2618,
          "minimum": 255.806,
          "maximum": 1899.8826,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1899.8826,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURETAPE-W/ 1.5MM NEEDLES",
      "code_information": [
        {
          "code": "3059187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 460,
          "minimum": 157.2578,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 333.822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-VERTEX DRILL 2.4MM",
      "code_information": [
        {
          "code": "3059197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 18503.6714,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRESSING-ALLEVYN 5X5CM FUD021",
      "code_information": [
        {
          "code": "3059209",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.8789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-KNOTLESS S-TAK STEP 3MM",
      "code_information": [
        {
          "code": "3059213",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 375.0258,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.0929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW OSC SAGITTAL xxMM",
      "code_information": [
        {
          "code": "3059220",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 8367.0806,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 452.8368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CLIP-HEMO DURACLIP 235CM 11MM",
      "code_information": [
        {
          "code": "3059232",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1410,
          "minimum": 482.0295,
          "maximum": 16632.951,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1023.237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT LG",
      "code_information": [
        {
          "code": "3059245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 39.9135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 39.9135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPECULLUM-VAG DISP W/LIGHT SM",
      "code_information": [
        {
          "code": "3059246",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 55,
          "minimum": 18.8026,
          "maximum": 2632.0213,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 39.9135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACK-POLAR COMBO 1232PP",
      "code_information": [
        {
          "code": "3059252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 907,
          "minimum": 310.0714,
          "maximum": 780.2083,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 658.2099,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-TRI STAPLE 2.0 SIG30AVM",
      "code_information": [
        {
          "code": "3059259",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2871,
          "minimum": 981.494,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2083.4847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BUR-DIAMOND ROUND 1.0MM",
      "code_information": [
        {
          "code": "3059273",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1277,
          "minimum": 151.2592,
          "maximum": 926.7189,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 926.7189,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PILLOW-ABDUCTION MED",
      "code_information": [
        {
          "code": "3059281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 279,
          "minimum": 95.3803,
          "maximum": 4504.9661,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 202.4703,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BINDER-ABDOMINAL 15\\\" ADJ ILIO",
      "code_information": [
        {
          "code": "3059288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 328,
          "minimum": 112.1317,
          "maximum": 6273.9202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 238.0296,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SIZER-IMPLANT 68MP ALL",
      "code_information": [
        {
          "code": "3059603",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 418,
          "minimum": 142.8995,
          "maximum": 2352.8591,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 303.3426,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CHECKPOINT 111645",
      "code_information": [
        {
          "code": "3059922",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 779,
          "minimum": 266.3127,
          "maximum": 664.5395,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 565.3203,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 3.2X140 143140",
      "code_information": [
        {
          "code": "3059924",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1195,
          "minimum": 408.5285,
          "maximum": 2945.1056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 867.2115,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ABC SINGLE FUNCTION",
      "code_information": [
        {
          "code": "3059973",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 850,
          "minimum": 290.5851,
          "maximum": 726.2666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 616.845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATCHER-STONE WITH TUB 840-750",
      "code_information": [
        {
          "code": "3059984",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 825,
          "minimum": 282.0385,
          "maximum": 4179.6476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 598.7025,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-GROUNDING DISP       7-382",
      "code_information": [
        {
          "code": "3059989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 82,
          "minimum": 28.0329,
          "maximum": 6650.3999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 59.5074,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-ISOLATOR  BIP   OSL2",
      "code_information": [
        {
          "code": "3059996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11959,
          "minimum": 627.8369,
          "maximum": 8678.6463,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8678.6463,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-LINEAR 60GRN      TX60G",
      "code_information": [
        {
          "code": "3060001",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 913,
          "minimum": 305.855,
          "maximum": 662.5641,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 662.5641,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-60MM GREEN        XR60G",
      "code_information": [
        {
          "code": "3060002",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 550,
          "minimum": 84.5272,
          "maximum": 399.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 399.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-RETROGRADE   RC014MIBB",
      "code_information": [
        {
          "code": "3060082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 935,
          "minimum": 68.9564,
          "maximum": 678.5295,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 678.5295,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ADAPTER-CORONARY PERFUSN 10004",
      "code_information": [
        {
          "code": "3060083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 477.1338,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 89.9868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRACTOR-FLEX IRIS     611.75",
      "code_information": [
        {
          "code": "3060129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 858,
          "minimum": 175.1715,
          "maximum": 622.6506,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 622.6506,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CARRIER-MESHER 8\\\"  7708-000-10",
      "code_information": [
        {
          "code": "3060132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 315,
          "minimum": 107.6874,
          "maximum": 228.5955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 228.5955,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-VESSEL           30003",
      "code_information": [
        {
          "code": "3060134",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 101,
          "minimum": 34.5284,
          "maximum": 1063.2632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 73.2957,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CATH-T-TUBE 16FR       0099830",
      "code_information": [
        {
          "code": "3060199",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 825.2524,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RETRIEVER-SUTURE MEDIUM   9893",
      "code_information": [
        {
          "code": "3060289",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 498,
          "minimum": 170.2487,
          "maximum": 3121.3893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 361.3986,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-UNIV     60-6010-001",
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        {
          "code": "3060315",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 68.9564,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 391.878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPHERZ-REFLECTIVE PK   PM 8005",
      "code_information": [
        {
          "code": "3060317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 143.4738,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 89.9868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSERT-SPRING CLIP 6MM  CSOFT6",
      "code_information": [
        {
          "code": "3060318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 258,
          "minimum": 88.2011,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 187.2306,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PACKING-SILVERSTEIN PK 1428010",
      "code_information": [
        {
          "code": "3060385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 209,
          "minimum": 71.4498,
          "maximum": 12457.1961,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 151.6713,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0 CT-2 Z332H",
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        {
          "code": "3060417",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 141,
          "minimum": 48.2029,
          "maximum": 784.101,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 102.3237,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PROGRAMMER-TEST STIM 3531",
      "code_information": [
        {
          "code": "3060442",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2604,
          "minimum": 259.1426,
          "maximum": 1889.7228,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1889.7228,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MINI HOOK 357501",
      "code_information": [
        {
          "code": "3060443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 414.2945,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 338.1762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 4.0MM 03.000.012S",
      "code_information": [
        {
          "code": "3060451",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 745,
          "minimum": 254.6893,
          "maximum": 540.6465,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 540.6465,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND S 5.0MM 03.000.015S",
      "code_information": [
        {
          "code": "3060452",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 540,
          "minimum": 184.607,
          "maximum": 391.878,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 391.878,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SAW 90X9.5 05.003.126S",
      "code_information": [
        {
          "code": "3060455",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 624,
          "minimum": 213.3237,
          "maximum": 1953.0232,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 452.8368,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INSTRUMENT-CAVITY CREATION 10M",
      "code_information": [
        {
          "code": "3060460",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3512,
          "minimum": 398.1676,
          "maximum": 2548.6584,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2548.6584,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-BUTTON PASSPORT",
      "code_information": [
        {
          "code": "3060472",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 519.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-LIPO 5MM PAL-508LL",
      "code_information": [
        {
          "code": "3060475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 740,
          "minimum": 252.98,
          "maximum": 1614.9144,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 537.018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IMPLANT-FAST FIX 360 KPSC",
      "code_information": [
        {
          "code": "3060478",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1344,
          "minimum": 459.4664,
          "maximum": 975.3408,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 975.3408,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU RIGHT 7210424",
      "code_information": [
        {
          "code": "3060485",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1334,
          "minimum": 456.0477,
          "maximum": 968.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 968.0838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU LEFT 7210423",
      "code_information": [
        {
          "code": "3060486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 939.7815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STRT 7210426",
      "code_information": [
        {
          "code": "3060488",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1295,
          "minimum": 442.715,
          "maximum": 939.7815,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 939.7815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-2.3MM CROSSPIN 62-23333",
      "code_information": [
        {
          "code": "3060489",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 499.8064,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1060.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PASSER-ACCU PASS STR 7210425",
      "code_information": [
        {
          "code": "3060494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1253,
          "minimum": 428.3567,
          "maximum": 909.3021,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 909.3021,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-SILICONE 8CM        205108",
      "code_information": [
        {
          "code": "3061090",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1750,
          "minimum": 598.2635,
          "maximum": 2541.377,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1269.975,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-SINGLE HOLE 1877-01-010",
      "code_information": [
        {
          "code": "3062492",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2040,
          "minimum": 95.6492,
          "maximum": 1480.428,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1480.428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-3' EPV100 VENT",
      "code_information": [
        {
          "code": "3068320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 172,
          "minimum": 58.8008,
          "maximum": 124.8204,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 124.8204,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SENSOR-PULSE OX PEDS MAXP",
      "code_information": [
        {
          "code": "3068323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 159,
          "minimum": 54.3565,
          "maximum": 283.0549,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 115.3863,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP VIBRATORY ACAPELLA",
      "code_information": [
        {
          "code": "3068325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 509,
          "minimum": 31.6977,
          "maximum": 369.3813,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 369.3813,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL PED W/7' TUBING",
      "code_information": [
        {
          "code": "3068327",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 199.0838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.3649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-BIPAP PERFORMATRAK LARGE",
      "code_information": [
        {
          "code": "3068330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 358,
          "minimum": 35.5904,
          "maximum": 259.8006,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 259.8006,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT DUAL LIMB",
      "code_information": [
        {
          "code": "3068331",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-ADULT CAPNOXYGEN C02-01",
      "code_information": [
        {
          "code": "3068332",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 76,
          "minimum": 25.9817,
          "maximum": 102.3224,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.1532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-ADULT/PED 8’ 58051",
      "code_information": [
        {
          "code": "3068333",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 7528.4818,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.5288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-MYOSURE            40-902",
      "code_information": [
        {
          "code": "3078533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 171,
          "minimum": 58.4589,
          "maximum": 3316.5804,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 124.0947,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-DURA           20-xxxx",
      "code_information": [
        {
          "code": "3078541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5964,
          "minimum": 398.1676,
          "maximum": 4328.0748,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4328.0748,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEPARATOR-DURAL           1314",
      "code_information": [
        {
          "code": "3078593",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 868.6282,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 519.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CATH INDWELLING SLIT 295-6",
      "code_information": [
        {
          "code": "3078730",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1562,
          "minimum": 533.9929,
          "maximum": 1133.5434,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1133.5434,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-KARLEN BALLOON    CS-01700",
      "code_information": [
        {
          "code": "3078823",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1149,
          "minimum": 207.4253,
          "maximum": 833.8293,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 833.8293,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 3000ML 0797208",
      "code_information": [
        {
          "code": "3078850",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 276.3817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 161.8311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU, DIALYSIS 2.5% 2L 5B9876",
      "code_information": [
        {
          "code": "3078852",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 497,
          "minimum": 28.3611,
          "maximum": 360.6729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 360.6729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOLU-NS IRRIG 1000ML  07138-09",
      "code_information": [
        {
          "code": "3078858",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 51,
          "minimum": 17.4351,
          "maximum": 865.8477,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-LAP L-HOOK E3773-45C",
      "code_information": [
        {
          "code": "3078982",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1254,
          "minimum": 428.6985,
          "maximum": 1022.6679,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 910.0278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MAS TLIF LIGHT   3400033",
      "code_information": [
        {
          "code": "3079040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2853,
          "minimum": 636.1784,
          "maximum": 2070.4221,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2070.4221,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CABLE-MULTILEAD TRIAL     3013",
      "code_information": [
        {
          "code": "3079055",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1144,
          "minimum": 391.0934,
          "maximum": 830.2008,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 830.2008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.0X13        AR-8400EX",
      "code_information": [
        {
          "code": "3079215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 330.1935,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 330.1935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-5.-X13 AR-8500EX",
      "code_information": [
        {
          "code": "3079228",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 454,
          "minimum": 155.2066,
          "maximum": 1306.2789,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 329.4678,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-FILTER        20400161S/10",
      "code_information": [
        {
          "code": "3079240",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 306,
          "minimum": 99.5419,
          "maximum": 222.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 222.0642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL G2 TIP 35CM",
      "code_information": [
        {
          "code": "3079250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3329,
          "minimum": 364.8016,
          "maximum": 2415.8553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2415.8553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 ABRADER    72201518",
      "code_information": [
        {
          "code": "3079252",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 656,
          "minimum": 224.2633,
          "maximum": 476.0592,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 476.0592,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.9 INCISOR    72201513",
      "code_information": [
        {
          "code": "3079253",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 637,
          "minimum": 217.7679,
          "maximum": 462.2709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 462.2709,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-2.0 FULLRADIUS 72201507",
      "code_information": [
        {
          "code": "3079254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 598,
          "minimum": 204.4352,
          "maximum": 433.9686,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 433.9686,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-3.5 FULL RADIUS 7205305",
      "code_information": [
        {
          "code": "3079257",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 455,
          "minimum": 155.5485,
          "maximum": 498.2656,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 330.1935,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 FULL RADIUM 7205306",
      "code_information": [
        {
          "code": "3079261",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 320.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHAVER-4.5 INCISOR     7205345",
      "code_information": [
        {
          "code": "3079262",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 151.1043,
          "maximum": 1761.1687,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 320.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-ENSEAL 45CM    NSLG2C45A",
      "code_information": [
        {
          "code": "3079282",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3167,
          "minimum": 1082.686,
          "maximum": 2298.2919,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2298.2919,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HARMONIC LAP 36\\\"   HAR36",
      "code_information": [
        {
          "code": "3079285",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3146,
          "minimum": 1075.5068,
          "maximum": 2283.0522,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2283.0522,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEAR-HS FOCUS 9CM CRVD  HAR9F",
      "code_information": [
        {
          "code": "3079290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2871,
          "minimum": 680.1103,
          "maximum": 2083.4847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2083.4847,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-INPUT 8FR PS    080011",
      "code_information": [
        {
          "code": "3079468",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 425.9726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.0387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-TUNNLER SM-LG    9009-s",
      "code_information": [
        {
          "code": "3079475",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 766,
          "minimum": 261.8685,
          "maximum": 555.8862,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 555.8862,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-RENAL 20CM      900-123",
      "code_information": [
        {
          "code": "3079482",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 432,
          "minimum": 147.6856,
          "maximum": 313.5024,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 313.5024,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEET-EXT BILATERAL DYNJP8004A",
      "code_information": [
        {
          "code": "3079499",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 2033.1016,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHIELD-CORNEAL DISP      E5699",
      "code_information": [
        {
          "code": "3079626",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 2980.1399,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-CAROTID ALL     2000-00s",
      "code_information": [
        {
          "code": "3079680",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 6136.0074,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909504",
      "code_information": [
        {
          "code": "3079703",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11962,
          "minimum": 2091.4921,
          "maximum": 8680.8234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8680.8234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5070",
      "code_information": [
        {
          "code": "3079707",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3761,
          "minimum": 1285.7537,
          "maximum": 2729.3577,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2729.3577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-SUNDT ENDART  NL850-5071",
      "code_information": [
        {
          "code": "3079709",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3761,
          "minimum": 1285.7537,
          "maximum": 11631.3876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2729.3577,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-PHACO .9MM  8065-750517",
      "code_information": [
        {
          "code": "3079736",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 429,
          "minimum": 146.66,
          "maximum": 7567.9649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 311.3253,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-SMALL VIT PLUS 1",
      "code_information": [
        {
          "code": "3079745",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1675,
          "minimum": 572.6236,
          "maximum": 7567.9649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1215.5475,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-STAR            AR-1606",
      "code_information": [
        {
          "code": "3079766",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 877,
          "minimum": 299.8155,
          "maximum": 636.4389,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 636.4389,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-XCEL 12MM        CB12LT",
      "code_information": [
        {
          "code": "3079770",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1106,
          "minimum": 378.1025,
          "maximum": 8681.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 802.6242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM KII          CFS22",
      "code_information": [
        {
          "code": "3079789",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 149.4942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-FIBER          AR-7209SN",
      "code_information": [
        {
          "code": "3079790",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1097,
          "minimum": 80.0784,
          "maximum": 796.0929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 796.0929,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM KII           CFS02",
      "code_information": [
        {
          "code": "3079791",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 144,
          "minimum": 49.2285,
          "maximum": 114.5566,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 104.5008,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-12MM THREADED KII CTS22",
      "code_information": [
        {
          "code": "3079792",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 206,
          "minimum": 70.4242,
          "maximum": 149.4942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 149.4942,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SLEEVE-5MM THREADED KII  CTS0S",
      "code_information": [
        {
          "code": "3079793",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 148,
          "minimum": 50.596,
          "maximum": 165.1617,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 107.4036,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SNARE-ROTATABLE OVAL",
      "code_information": [
        {
          "code": "3079795",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 297,
          "minimum": 101.5339,
          "maximum": 8681.8332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 215.5329,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-SILICONE         400561",
      "code_information": [
        {
          "code": "3079975",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 550,
          "minimum": 188.0257,
          "maximum": 399.135,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 399.135,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER MINI        1500",
      "code_information": [
        {
          "code": "3079992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 425.9859,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 425.9859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER SMALL       1500",
      "code_information": [
        {
          "code": "3079994",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 554,
          "minimum": 189.3931,
          "maximum": 402.0378,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 402.0378,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-DENVER PETITE      1500",
      "code_information": [
        {
          "code": "3079996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 587,
          "minimum": 200.6747,
          "maximum": 8572.8376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 425.9859,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-AGGRESSIVE 3.5   283315",
      "code_information": [
        {
          "code": "3080062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 415.8261,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 415.8261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-ULTRA AGGRESSIVE 283325",
      "code_information": [
        {
          "code": "3080067",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 573,
          "minimum": 195.8886,
          "maximum": 1213.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 415.8261,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.5MM AR-1204AS-95",
      "code_information": [
        {
          "code": "3080073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2182,
          "minimum": 745.9491,
          "maximum": 1583.4774,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1583.4774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 10MM AR-1204AS-100",
      "code_information": [
        {
          "code": "3080074",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2181,
          "minimum": 745.6073,
          "maximum": 1582.7517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1582.7517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUTTER-FLIP 9.0MM AR1204AS90",
      "code_information": [
        {
          "code": "3080075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1819,
          "minimum": 207.4253,
          "maximum": 1320.0483,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1320.0483,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPLINT-OPTIMOLD NASAL   PS1688",
      "code_information": [
        {
          "code": "3080204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 195.7472,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 88.5354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-MEROCEL MEDIUM   440402",
      "code_information": [
        {
          "code": "3080355",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 352,
          "minimum": 113.4444,
          "maximum": 255.4464,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 255.4464,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-EGIA 60 MED   EGIA60AVM",
      "code_information": [
        {
          "code": "3080925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 477.6899,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1137.1719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-ENDOCLIP MULTI    ER320",
      "code_information": [
        {
          "code": "3080932",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 859,
          "minimum": 293.6619,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 623.3763,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR VASCULAR  TX30V",
      "code_information": [
        {
          "code": "3081085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 961,
          "minimum": 81.7467,
          "maximum": 697.3977,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 697.3977,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT 12”",
      "code_information": [
        {
          "code": "3081101",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.6779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY BOLUS EXT RIGHT",
      "code_information": [
        {
          "code": "3081102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 106.6779,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.6779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MICKEY RT ANGLE Y PORT 12”",
      "code_information": [
        {
          "code": "3081103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 147,
          "minimum": 50.2541,
          "maximum": 117.8932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 106.6779,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-MULTIDEBRIEDER TS101DC",
      "code_information": [
        {
          "code": "3081129",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 594,
          "minimum": 203.0677,
          "maximum": 5771.7619,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 431.0658,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLE-POLYSORB 55      SZ 200",
      "code_information": [
        {
          "code": "3081173",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4940,
          "minimum": 497.1534,
          "maximum": 3584.958,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3584.958,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN INSORB 2030",
      "code_information": [
        {
          "code": "3081400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 894,
          "minimum": 305.6272,
          "maximum": 4780.7917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 648.7758,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZS ECS's",
      "code_information": [
        {
          "code": "3081408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1763,
          "minimum": 602.7077,
          "maximum": 4780.7917,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1279.4091,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CIRCULAR ALL SZ CDHxxA",
      "code_information": [
        {
          "code": "3081415",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1570,
          "minimum": 536.7278,
          "maximum": 1451.9771,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1139.349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWER  PLEE60A",
      "code_information": [
        {
          "code": "3081416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2611,
          "minimum": 892.6091,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1894.8027,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-INTERNAL EEA   EEAXL25",
      "code_information": [
        {
          "code": "3081425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1376.3475,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-FLEX 60 POWERED PCE60A",
      "code_information": [
        {
          "code": "3081432",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2475,
          "minimum": 846.1155,
          "maximum": 1796.1075,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1796.1075,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 45       EC45A",
      "code_information": [
        {
          "code": "3081433",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2038,
          "minimum": 696.7206,
          "maximum": 1478.9766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1478.9766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ECHELON 60       EC60A",
      "code_information": [
        {
          "code": "3081436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2635,
          "minimum": 900.8139,
          "maximum": 1912.2195,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1912.2195,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-EGIA HANDLE  EGIAUSTND",
      "code_information": [
        {
          "code": "3081443",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2985,
          "minimum": 1020.4666,
          "maximum": 5395.8383,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2166.2145,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDO GIA UNIVER 030449",
      "code_information": [
        {
          "code": "3081491",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2640,
          "minimum": 464.8996,
          "maximum": 1915.848,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1915.848,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-THICK TISSUE      TRT75",
      "code_information": [
        {
          "code": "3081494",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 836,
          "minimum": 285.799,
          "maximum": 3752.0067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 606.6852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN             PMW35",
      "code_information": [
        {
          "code": "3081502",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 61.171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.3303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN VISISTAT STR 35WD",
      "code_information": [
        {
          "code": "3081503",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 110,
          "minimum": 37.6051,
          "maximum": 2614.7822,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 79.827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAYS-SURGICAL PACK    3311-8G",
      "code_information": [
        {
          "code": "3081506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.4316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR CUTTER   TLC-75",
      "code_information": [
        {
          "code": "3081530",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1365,
          "minimum": 466.6455,
          "maximum": 990.5805,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 990.5805,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-LINEAR 60BL      TX60B",
      "code_information": [
        {
          "code": "3081535",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 904,
          "minimum": 309.0458,
          "maximum": 1678.8659,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 656.0328,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR  40B     CS40B",
      "code_information": [
        {
          "code": "3081542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3019,
          "minimum": 1032.09,
          "maximum": 2190.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2190.8883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-CONTOUR 40G      CS40G",
      "code_information": [
        {
          "code": "3081544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3019,
          "minimum": 1032.09,
          "maximum": 2190.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2190.8883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-ENDOPATH VASC PVE35A",
      "code_information": [
        {
          "code": "3081550",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2231,
          "minimum": 762.7005,
          "maximum": 1619.0367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1619.0367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-HEAVY WIRE 90    TLH90",
      "code_information": [
        {
          "code": "3081554",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 791,
          "minimum": 270.4151,
          "maximum": 574.0287,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 574.0287,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STAPLER-SKIN REGULAR     PMR35",
      "code_information": [
        {
          "code": "3081569",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 12302.6003,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.0387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A28-2",
      "code_information": [
        {
          "code": "3082047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21603,
          "minimum": 7385.3066,
          "maximum": 15677.2971,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15677.2971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-INTRANEAL CUFF    A25-25",
      "code_information": [
        {
          "code": "3082066",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 21603,
          "minimum": 7385.3066,
          "maximum": 15677.2971,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 15677.2971,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STENT-AAA MAIN    ETCF3636C49E",
      "code_information": [
        {
          "code": "3082068",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 20042,
          "minimum": 6851.6555,
          "maximum": 14544.4794,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 14544.4794,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STICK-FIBER            AR-7209",
      "code_information": [
        {
          "code": "3082089",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 597,
          "minimum": 204.0933,
          "maximum": 27356.7834,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 433.2429,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOCKINETTE-BARRIER   NON22535",
      "code_information": [
        {
          "code": "3082135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 366.4699,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.0733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STRAP-ANKLE FOOT        014407",
      "code_information": [
        {
          "code": "3082217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 659,
          "minimum": 225.2889,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 478.2363,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STYLET-STRAIGHT           1123",
      "code_information": [
        {
          "code": "3082330",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 274,
          "minimum": 93.671,
          "maximum": 198.8418,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 198.8418,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUMP-PERICARDIAL 1/4 CONNECTOR",
      "code_information": [
        {
          "code": "3082395",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 164.6056,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.3517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURG-STRIP 1/2X6       80-1451",
      "code_information": [
        {
          "code": "3082416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 296,
          "minimum": 101.192,
          "maximum": 960.3847,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 214.8072,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUPRALOOP-BRUCKER/MESSROGHLI",
      "code_information": [
        {
          "code": "3082421",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1727,
          "minimum": 498.2656,
          "maximum": 1253.2839,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1253.2839,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SURGICEL-NUKNITT 3X4      1943",
      "code_information": [
        {
          "code": "3082430",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 306.3109,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 650.2272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC-0       173024",
      "code_information": [
        {
          "code": "3082450",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 294.6875,
          "maximum": 625.5534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 625.5534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SURGIDAC 2-0 173023",
      "code_information": [
        {
          "code": "3082453",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 862,
          "minimum": 207.4253,
          "maximum": 625.5534,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 625.5534,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0 698G",
      "code_information": [
        {
          "code": "3082542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 70,
          "minimum": 23.9305,
          "maximum": 235.2303,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-GORETEX CV-3      3N06A",
      "code_information": [
        {
          "code": "3082544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 423,
          "minimum": 144.6088,
          "maximum": 306.9711,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 306.9711,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 1          J947H",
      "code_information": [
        {
          "code": "3082558",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 4065.091,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONO PDSII        Z740D",
      "code_information": [
        {
          "code": "3082562",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 305,
          "minimum": 104.2688,
          "maximum": 221.3385,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 221.3385,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-ALIANCE        5060-05",
      "code_information": [
        {
          "code": "3082566",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 1441.4112,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 271.4118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYRINGE-FLOSEAL 10ML   1503352",
      "code_information": [
        {
          "code": "3082592",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2592,
          "minimum": 886.1137,
          "maximum": 5547.0975,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1881.0144,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CHARGING NEMA   3730ANS",
      "code_information": [
        {
          "code": "3082996",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3949,
          "minimum": 1350.0243,
          "maximum": 2865.7893,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2865.7893,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-ACCESSORY           502",
      "code_information": [
        {
          "code": "3083003",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 4011,
          "minimum": 1371.22,
          "maximum": 2910.7827,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2910.7827,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-BIOGLUE 5ML  BG3515-5US",
      "code_information": [
        {
          "code": "3083007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5122,
          "minimum": 760.7448,
          "maximum": 3717.0354,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 3717.0354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANS CATH 10\\\" PM040-A",
      "code_information": [
        {
          "code": "3083014",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1368,
          "minimum": 467.6711,
          "maximum": 992.7576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 992.7576,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "IRRIGATOR-CYSTO 25X5/8  581610",
      "code_information": [
        {
          "code": "3083019",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 50,
          "minimum": 17.0932,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 36.285,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-CLOSURE VNUS        CFP",
      "code_information": [
        {
          "code": "3083021",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 163.4114,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 346.8846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION CATH  PM010-A",
      "code_information": [
        {
          "code": "3083022",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 435,
          "minimum": 148.7112,
          "maximum": 333.1039,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 315.6795,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EXPANSION 5\\\"    PM020-A",
      "code_information": [
        {
          "code": "3083023",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 599,
          "minimum": 204.7771,
          "maximum": 610.0417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 434.6943,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-COLLECTION   003984-901",
      "code_information": [
        {
          "code": "3083083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 204,
          "minimum": 69.7404,
          "maximum": 867.516,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 148.0428,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-STERIDRAPE 8 7/8   1075",
      "code_information": [
        {
          "code": "3083104",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 95,
          "minimum": 32.4772,
          "maximum": 832.4817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.9415,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-URETERAL DIAL   240-100",
      "code_information": [
        {
          "code": "3083141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1497,
          "minimum": 511.7717,
          "maximum": 1086.3729,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1086.3729,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TACKER-PROTACK DEVICE 5MM",
      "code_information": [
        {
          "code": "3083191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3464,
          "minimum": 331.4356,
          "maximum": 2513.8248,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2513.8248,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAK-BB AR-13226",
      "code_information": [
        {
          "code": "3083200",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 596,
          "minimum": 203.7515,
          "maximum": 575.5635,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 432.5172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-BONE SCREW 3.5X50  311.349",
      "code_information": [
        {
          "code": "3083203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1035,
          "minimum": 353.8301,
          "maximum": 1343.5376,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 751.0995,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAP-4.35 2883-02-043",
      "code_information": [
        {
          "code": "3083212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2416,
          "minimum": 522.734,
          "maximum": 1753.2912,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1753.2912,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BATTERY-IQ DISPOSABLE 72-1010",
      "code_information": [
        {
          "code": "3083214",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 310.8599,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 682.158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-TVT DEVICE .5\\\"X18\\\" 810041",
      "code_information": [
        {
          "code": "3083229",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5520.9608,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIGERTAPE-          AR-7237-7T",
      "code_information": [
        {
          "code": "3083486",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 520,
          "minimum": 177.7697,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 377.364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-APPLICATOR            PRS2",
      "code_information": [
        {
          "code": "3083597",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 134.5762,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 346.8846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-BIOGLUE FAN        BGST-12",
      "code_information": [
        {
          "code": "3083615",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 242,
          "minimum": 82.7313,
          "maximum": 593.3587,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 175.6194,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE ALL    UMx67x's",
      "code_information": [
        {
          "code": "3083622",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1067,
          "minimum": 207.4253,
          "maximum": 774.3219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 774.3219,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-EVICEL RIGID 35CM     3908",
      "code_information": [
        {
          "code": "3083637",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 338.1762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-CURVED DISP I&A 8065751512",
      "code_information": [
        {
          "code": "3083715",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.4316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DISPOSABLE POLYMER I/A",
      "code_information": [
        {
          "code": "3083720",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 222,
          "minimum": 75.894,
          "maximum": 415.4067,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 161.1054,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-TURBOSONICS     8065750853",
      "code_information": [
        {
          "code": "3083760",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 747,
          "minimum": 50.6051,
          "maximum": 542.0979,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 542.0979,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TOOL-EMBLEM TUNNELING 4711",
      "code_information": [
        {
          "code": "3084601",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 1928.4597,
          "maximum": 5623.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAP-LUKI MUCOUS SPEC  8646-04",
      "code_information": [
        {
          "code": "3084800",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.9069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH UNCUFF FLANGE XL 6",
      "code_information": [
        {
          "code": "3084821",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 321.353,
          "maximum": 726.2666,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 682.158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA70",
      "code_information": [
        {
          "code": "3084824",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 947.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRACH-BIVONA FLANGE 75HA80",
      "code_information": [
        {
          "code": "3084827",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1345,
          "minimum": 100.098,
          "maximum": 976.0665,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 976.0665,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-FOLEY W/METER ALL P4PxxSD",
      "code_information": [
        {
          "code": "3084870",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 130.626,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 130.626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAY-BETADINE PREP   DYND70672",
      "code_information": [
        {
          "code": "3084876",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 77,
          "minimum": 26.3236,
          "maximum": 3099.7014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 55.8789,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRANSDUCER-SYSTEM 1    4609764",
      "code_information": [
        {
          "code": "3084884",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 154,
          "minimum": 52.6472,
          "maximum": 111.7578,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 111.7578,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TRAPS-FINGER DISP PACK 9900s",
      "code_information": [
        {
          "code": "3084885",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 190,
          "minimum": 64.9543,
          "maximum": 12260.3367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-LAP CB EXPLOR    G26908",
      "code_information": [
        {
          "code": "3084925",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3560,
          "minimum": 443.2117,
          "maximum": 2583.492,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 2583.492,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-SOLU IRRISEPT .5% CHG",
      "code_information": [
        {
          "code": "3084928",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 797,
          "minimum": 272.4663,
          "maximum": 3137.5162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 578.3829,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SYSTEM-EZPAP 26-23-0757",
      "code_information": [
        {
          "code": "3084992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 7593.5455,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 204.6474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFF74",
      "code_information": [
        {
          "code": "3085110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 503.8266,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 5MM IAS5-100LP",
      "code_information": [
        {
          "code": "3085111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 906,
          "minimum": 174.6154,
          "maximum": 657.4842,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 657.4842,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM THREADED     CTF73",
      "code_information": [
        {
          "code": "3085112",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 523.2901,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 227.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-AIRSEAL 12MM IAS12-100L",
      "code_information": [
        {
          "code": "3085113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 941,
          "minimum": 141.2494,
          "maximum": 682.8837,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 682.8837,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM THREATED      CTF03",
      "code_information": [
        {
          "code": "3085117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 184.3278,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 184.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-8MM KII OPTICAL   COQ19",
      "code_information": [
        {
          "code": "3085120",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 195.2133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085125",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII FIOS     CFFxx",
      "code_information": [
        {
          "code": "3085130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 232.9497,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.9497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR47",
      "code_information": [
        {
          "code": "3085135",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 227.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM KII BLUNT    COR85",
      "code_information": [
        {
          "code": "3085137",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 109.7386,
          "maximum": 315.3087,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 232.9497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM KII OPTICAL  COR37",
      "code_information": [
        {
          "code": "3085140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 567,
          "minimum": 193.8374,
          "maximum": 411.4719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 411.4719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-15MM LONG         C0R39",
      "code_information": [
        {
          "code": "3085142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 567,
          "minimum": 149.5909,
          "maximum": 411.4719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 411.4719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-5MM KII FIOS      CFFxx",
      "code_information": [
        {
          "code": "3085145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 195.2133,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 195.2133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-12MM LONG BLADED CFB71",
      "code_information": [
        {
          "code": "3085160",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 490.4802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-THORACOPOR 11.5  179303",
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        {
          "code": "3085163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 882,
          "minimum": 178.5081,
          "maximum": 640.0674,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 640.0674,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-11MM THREADED     CTF33",
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        {
          "code": "3085165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 321,
          "minimum": 109.7386,
          "maximum": 1116.0927,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 232.9497,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-SPLIT           82-4095",
      "code_information": [
        {
          "code": "3085170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2007,
          "minimum": 268.0402,
          "maximum": 1456.4799,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1456.4799,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL BLADELESS     B8LT",
      "code_information": [
        {
          "code": "3085202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 482,
          "minimum": 164.7789,
          "maximum": 760.1887,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 349.7874,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-VERSASTEP LONG VS101505",
      "code_information": [
        {
          "code": "3085203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1367,
          "minimum": 467.3293,
          "maximum": 992.0319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 992.0319,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-XCEL 5MM           B5LT",
      "code_information": [
        {
          "code": "3085207",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1543,
          "minimum": 390.3822,
          "maximum": 1119.7551,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1119.7551,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-BIO PREP BONE PREP",
      "code_information": [
        {
          "code": "3085533",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1349,
          "minimum": 100.6541,
          "maximum": 978.9693,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 978.9693,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INSERTION 8.0FR MEGA IAB",
      "code_information": [
        {
          "code": "3085537",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1496,
          "minimum": 511.4298,
          "maximum": 4893.68,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1085.6472,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ARMSTRONG TEFLON DRAIN",
      "code_information": [
        {
          "code": "3085540",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 223,
          "minimum": 76.2359,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 161.8311,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-TIBIAL 111651",
      "code_information": [
        {
          "code": "3085541",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 426,
          "minimum": 145.6344,
          "maximum": 757.4082,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 309.1482,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-PROCEDURE TRACKING 107130",
      "code_information": [
        {
          "code": "3085542",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1362,
          "minimum": 225.2205,
          "maximum": 988.4034,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 988.4034,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-DRAPE 111320",
      "code_information": [
        {
          "code": "3085543",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 405,
          "minimum": 138.4553,
          "maximum": 454.3337,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 293.9085,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CHECKPOINT-3.5 HEX IMPACTION",
      "code_information": [
        {
          "code": "3085544",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 817,
          "minimum": 279.3036,
          "maximum": 592.8969,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 592.8969,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PIN-BONE 144140",
      "code_information": [
        {
          "code": "3085545",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 945,
          "minimum": 323.0623,
          "maximum": 685.7865,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 685.7865,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-COLLAR BUTTON ULTRASIL",
      "code_information": [
        {
          "code": "3085560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 133,
          "minimum": 45.468,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 96.5181,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-ENDO EXCEL 15MM   B15LT",
      "code_information": [
        {
          "code": "3085620",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1548,
          "minimum": 529.2068,
          "maximum": 1123.3836,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1123.3836,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR ARMSTRONG    10-56121",
      "code_information": [
        {
          "code": "3085635",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 155.2998,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 155.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-EAR PAPARELLA 1.14MM",
      "code_information": [
        {
          "code": "3085636",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 214,
          "minimum": 73.1591,
          "maximum": 881.4185,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 155.2998,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACHEAL EMG  8229307",
      "code_information": [
        {
          "code": "3085638",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1585,
          "minimum": 88.976,
          "maximum": 1150.2345,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1150.2345,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-ENDOTRACH ALL SZS 822970x",
      "code_information": [
        {
          "code": "3085644",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2759,
          "minimum": 207.9814,
          "maximum": 2002.2063,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2002.2063,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-GASTRO MIC 20FR   0100-20",
      "code_information": [
        {
          "code": "3085648",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 491.0363,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 271.4118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-KAMVAC            5300-00",
      "code_information": [
        {
          "code": "3085723",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 883,
          "minimum": 301.8667,
          "maximum": 1026.5606,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 640.7931,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-MOSS GASTROSTOMY  5-17719",
      "code_information": [
        {
          "code": "3085779",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1846,
          "minimum": 375.9236,
          "maximum": 1339.6422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1339.6422,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-T MODIFIED        24-0072",
      "code_information": [
        {
          "code": "3085882",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 230.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 230.7726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-COLLECTION DISP BKT-506",
      "code_information": [
        {
          "code": "3086006",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 83.415,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 219.1614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OXYFLEX        SA008000",
      "code_information": [
        {
          "code": "3086095",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.2797,
          "maximum": 580.5684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AQUILEX INFLOW  AQL-110",
      "code_information": [
        {
          "code": "3086102",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1044,
          "minimum": 356.9069,
          "maximum": 757.6308,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 757.6308,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      80-9102",
      "code_information": [
        {
          "code": "3086103",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 715,
          "minimum": 99.5419,
          "maximum": 518.8755,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 518.8755,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATION      5120-10",
      "code_information": [
        {
          "code": "3086105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 229,
          "minimum": 78.2871,
          "maximum": 535.5243,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 166.1853,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-AIRSEAL ASM-EVAC",
      "code_information": [
        {
          "code": "3086106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 963,
          "minimum": 301.4062,
          "maximum": 698.8491,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 698.8491,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-IRRIGATOR STR  18-95522",
      "code_information": [
        {
          "code": "3086107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 542,
          "minimum": 43.3758,
          "maximum": 393.3294,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 393.3294,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LASER VACUUM    VT10424",
      "code_information": [
        {
          "code": "3086109",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 78,
          "minimum": 26.6655,
          "maximum": 93.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 56.6046,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-LIPOSUCTION   DYND50112",
      "code_information": [
        {
          "code": "3086110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 57.7752,
          "maximum": 425.4165,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 122.6433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-MAIN PUMP       AR-6410",
      "code_information": [
        {
          "code": "3086111",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 765,
          "minimum": 99.5419,
          "maximum": 555.1605,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 555.1605,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/4\\\"X1/16\\\"X8'      3108",
      "code_information": [
        {
          "code": "3086139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 132,
          "minimum": 45.1262,
          "maximum": 279.1622,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 95.7924,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-OUTFLOW         AR-6430",
      "code_information": [
        {
          "code": "3086141",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 364.3014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO      284508",
      "code_information": [
        {
          "code": "3086142",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 450,
          "minimum": 153.8392,
          "maximum": 338.6649,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 326.565,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-PUMP ARTHRO IRRIG OUT",
      "code_information": [
        {
          "code": "3086144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 609,
          "minimum": 109.5517,
          "maximum": 441.9513,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 441.9513,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-ASPIRATION AT-10003-6",
      "code_information": [
        {
          "code": "3086181",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 197,
          "minimum": 67.3474,
          "maximum": 349.7869,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 142.9629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TISSEEL         0600065",
      "code_information": [
        {
          "code": "3086182",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 629,
          "minimum": 112.8883,
          "maximum": 456.4653,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 456.4653,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-TRANSDUCER 48 61000",
      "code_information": [
        {
          "code": "3086185",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 69.3986,
          "maximum": 165.7178,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.3171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ARTHREX-TIB CANN      AR-1802D",
      "code_information": [
        {
          "code": "3086190",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 298,
          "minimum": 101.8757,
          "maximum": 456.5581,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 216.2586,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-& TIP-SMALL   9009-18",
      "code_information": [
        {
          "code": "3086203",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 821,
          "minimum": 280.6711,
          "maximum": 595.7997,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 595.7997,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER & TIP-LARGE   9009-16",
      "code_information": [
        {
          "code": "3086205",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 724,
          "minimum": 247.5102,
          "maximum": 1804.5445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 525.4068,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUNNELER-STIMULATOR LEAD   402",
      "code_information": [
        {
          "code": "3086210",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3245,
          "minimum": 207.4253,
          "maximum": 2354.8965,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2354.8965,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-KNEE SUPPORT 79-82160",
      "code_information": [
        {
          "code": "3086407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 504.9388,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.4316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ACCESS 70x-xxxx ALL SIZES",
      "code_information": [
        {
          "code": "3086409",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 388,
          "minimum": 132.6436,
          "maximum": 341.4454,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 281.5716,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RELOAD-ENDOSTITCH 2-0   170057",
      "code_information": [
        {
          "code": "3086965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 813,
          "minimum": 277.9361,
          "maximum": 813.0182,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 589.9941,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VAC-SUPER TURBO     ASC4250-01",
      "code_information": [
        {
          "code": "3087110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 58.9466,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1060.9734,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP CVD ALL 21500s",
      "code_information": [
        {
          "code": "3087119",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 36.2377,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-CURVED 7MM     21853",
      "code_information": [
        {
          "code": "3087130",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 72.57,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.57,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 8MM CVD   20317",
      "code_information": [
        {
          "code": "3087132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 85,
          "minimum": 29.0585,
          "maximum": 2133.1996,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 61.6845,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VOICE-PROLARYN        8044M0K5",
      "code_information": [
        {
          "code": "3087140",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3836,
          "minimum": 1311.3936,
          "maximum": 8143.5284,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2783.7852,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVULATOME-LEMAITRE   1009-00",
      "code_information": [
        {
          "code": "3087919",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 13534,
          "minimum": 870.8526,
          "maximum": 9821.6238,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 9821.6238,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-DRILL 2.5MM AR-8916-14",
      "code_information": [
        {
          "code": "3087939",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 812,
          "minimum": 277.5943,
          "maximum": 589.2684,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 589.2684,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 UNDYED    VLOCM1904",
      "code_information": [
        {
          "code": "3088955",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 7.7854,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 392.6037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 3-0        J761D",
      "code_information": [
        {
          "code": "3088965",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 182,
          "minimum": 62.2194,
          "maximum": 309.7477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 132.0774,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-3-0 VIOLET    VLOCM0804",
      "code_information": [
        {
          "code": "3088967",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 557,
          "minimum": 58.9466,
          "maximum": 404.2149,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 404.2149,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 4-0    MCP496G",
      "code_information": [
        {
          "code": "3088972",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 7.7854,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J441",
      "code_information": [
        {
          "code": "3088976",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 34.4782,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8.7084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 5-0 PS2     1666G",
      "code_information": [
        {
          "code": "3088979",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 4-0        J218H",
      "code_information": [
        {
          "code": "3088985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 12,
          "minimum": 4.1024,
          "maximum": 8.7084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8.7084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 5-0      Y495G",
      "code_information": [
        {
          "code": "3088991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 444.3239,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 3-0       D5526",
      "code_information": [
        {
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            }
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    {
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          "code": "3088993",
          "type": "LOCAL"
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          "code": "0270",
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        }
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        {
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    {
      "description": "SUTURE-CAPIO 0  ALL  833-000s",
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          "code": "3088998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
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          ]
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    {
      "description": "SUTURE-VICRYL 0          J727D",
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        {
          "code": "0270",
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        }
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            }
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      ],
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        {
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            }
          ]
        }
      ],
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    {
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        {
          "code": "0270",
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          "minimum": 50.596,
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            {
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            }
          ]
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    {
      "description": "SUTURE-VICRYL 0          J740D",
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        {
          "code": "0270",
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        }
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        {
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          "payers_information": [
            {
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      ],
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    {
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        {
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            }
          ]
        }
      ],
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    },
    {
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        {
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        }
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        {
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    {
      "description": "SUTURE-PROLENE 6-0       8806H",
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          "code": "3089027",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
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        {
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            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z990G",
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          "code": "3089030",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0        J834G",
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        {
          "code": "3089039",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J833G",
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        {
          "code": "3089042",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 1         8824G",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
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        {
          "code": "0270",
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        }
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
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          "type": "LOCAL"
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        {
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        }
      ],
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        {
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          "minimum": 35.5539,
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          "payers_information": [
            {
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            }
          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        },
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          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-PROLENE 2-0       8623H",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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        }
      ],
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    },
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        },
        {
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        }
      ],
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          "payers_information": [
            {
              "payer_name": "Anthem",
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          ]
        }
      ],
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    },
    {
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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        {
          "code": "0270",
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-PROLENE 2-0       8523H",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "maximum": 112.8883,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-PROLENE 6-0       8706H",
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        {
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          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 69.3986,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8805H",
      "code_information": [
        {
          "code": "3089105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
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          "minimum": 76.2359,
          "maximum": 161.8311,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 6-0       8709H",
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        {
          "code": "3089106",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 90.9361,
          "maximum": 193.0362,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8720H",
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        {
          "code": "3089110",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 50.6051,
          "maximum": 142.2372,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8556H",
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        {
          "code": "3089113",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 31.1097,
          "maximum": 66.0387,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       8710H",
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        {
          "code": "3089114",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 30.426,
          "maximum": 133.464,
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          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8304H",
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        {
          "code": "3089117",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 82.0476,
          "maximum": 174.168,
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          ]
        }
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      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       8703H",
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        {
          "code": "3089121",
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        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 85.8081,
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          "payers_information": [
            {
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 5-0 J213H",
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        {
          "code": "3089123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-LASSO       AR-4068-xxx",
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        {
          "code": "3089131",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1462,
          "minimum": 33.9221,
          "maximum": 1060.9734,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         G124H",
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        {
          "code": "3089132",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 0         U256H",
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        {
          "code": "3089133",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 42.0906,
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            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
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        {
          "code": "3089145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 19.4863,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       1792G",
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          "code": "3089146",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 91.2779,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 6-0        790G",
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          "code": "3089147",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 179.9736,
          "payers_information": [
            {
              "payer_name": "Anthem",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 0       L104G",
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        {
          "code": "3089150",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 22.2212,
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          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 47.1705,
              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       G172H",
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        {
          "code": "3089154",
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        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 33.9221,
          "maximum": 80.5527,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U203",
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        {
          "code": "3089156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 20.8538,
          "maximum": 53.3856,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 44.2677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1637G",
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        {
          "code": "3089157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 32.819,
          "maximum": 69.6672,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 6-0     1916G",
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        {
          "code": "3089161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 71.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 4-0     1824H",
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        {
          "code": "3089172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 43.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 3-0          A304H",
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        {
          "code": "3089177",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 40.6392,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 40.6392,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 5-0          K890H",
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        {
          "code": "3089195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
          "setting": "inpatient",
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          "minimum": 7.7854,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 60.9588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
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    },
    {
      "description": "SUTURE-SILK 4-0           709H",
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        {
          "code": "3089202",
          "type": "LOCAL"
        },
        {
          "code": "0270",
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        }
      ],
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        {
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          "minimum": 40.3401,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0  X524H",
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        {
          "code": "3089204",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 46.4448,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5        B449T",
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        {
          "code": "3089212",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
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        {
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          "minimum": 7.7854,
          "maximum": 51.5247,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 4-0      X204H",
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        {
          "code": "3089217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 37.2633,
          "maximum": 79.1013,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "count": "0",
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            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 3-0      X936H",
      "code_information": [
        {
          "code": "3089226",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
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          "minimum": 30.0841,
          "maximum": 93.9809,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 63.8616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 5-0      X727H",
      "code_information": [
        {
          "code": "3089227",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 169,
          "minimum": 7.7854,
          "maximum": 122.6433,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 122.6433,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0        690G",
      "code_information": [
        {
          "code": "3089238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 5-0       1666H",
      "code_information": [
        {
          "code": "3089239",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 3-0       1663H",
      "code_information": [
        {
          "code": "3089244",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 7.7854,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.6219,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 0             Z340H",
      "code_information": [
        {
          "code": "3089254",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 7.7854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7.257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 0         L880G",
      "code_information": [
        {
          "code": "3089258",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 65,
          "minimum": 7.7854,
          "maximum": 47.1705,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.1705,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      SXP82",
      "code_information": [
        {
          "code": "3089266",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 607,
          "minimum": 207.512,
          "maximum": 440.4999,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 440.4999,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND2-0       SXP86",
      "code_information": [
        {
          "code": "3089267",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 666,
          "minimum": 7.7854,
          "maximum": 483.3162,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 483.3162,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X927H",
      "code_information": [
        {
          "code": "3089281",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.8616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 1             Z879G",
      "code_information": [
        {
          "code": "3089283",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.0733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 4-0 Z494G",
      "code_information": [
        {
          "code": "3089284",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 84,
          "minimum": 28.7166,
          "maximum": 60.9588,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.9588,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MONOCRYL 3-0      Y497G",
      "code_information": [
        {
          "code": "3089286",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 91,
          "minimum": 31.1097,
          "maximum": 66.0387,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.0387,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0        687G",
      "code_information": [
        {
          "code": "3089287",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 94,
          "minimum": 32.1353,
          "maximum": 68.2158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 68.2158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X513H",
      "code_information": [
        {
          "code": "3089288",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 120.1176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.7191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2 MX69G",
      "code_information": [
        {
          "code": "3089290",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 216,
          "minimum": 73.8428,
          "maximum": 215.2107,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 156.7512,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS O EZ10G",
      "code_information": [
        {
          "code": "3089291",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 280.8459,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 280.8459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 0          EJ10G",
      "code_information": [
        {
          "code": "3089292",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 387,
          "minimum": 132.3017,
          "maximum": 345.8942,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 280.8459,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 5-0       M8720",
      "code_information": [
        {
          "code": "3089293",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 622,
          "minimum": 212.6399,
          "maximum": 451.3854,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 451.3854,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 7-0       M8303",
      "code_information": [
        {
          "code": "3089294",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 778,
          "minimum": 7.7854,
          "maximum": 564.5946,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 564.5946,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 5-0       U202H",
      "code_information": [
        {
          "code": "3089307",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 61,
          "minimum": 20.8538,
          "maximum": 44.2677,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.2677,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       U213H",
      "code_information": [
        {
          "code": "3089308",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 57,
          "minimum": 19.4863,
          "maximum": 49.4929,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 41.3649,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PROLENE 2-0       8843H",
      "code_information": [
        {
          "code": "3089314",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 89,
          "minimum": 30.426,
          "maximum": 100.6541,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 64.5873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6-0        J555G",
      "code_information": [
        {
          "code": "3089316",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 181,
          "minimum": 61.8775,
          "maximum": 131.3517,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 131.3517,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 0            C027D",
      "code_information": [
        {
          "code": "3089318",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 168,
          "minimum": 57.4333,
          "maximum": 121.9176,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 121.9176,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 0        CX45D",
      "code_information": [
        {
          "code": "3089320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 207,
          "minimum": 70.766,
          "maximum": 150.2199,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 150.2199,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NYLON 8-0         2815G",
      "code_information": [
        {
          "code": "3089323",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 203,
          "minimum": 35.0343,
          "maximum": 147.3171,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 147.3171,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X523H",
      "code_information": [
        {
          "code": "3089324",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 63,
          "minimum": 21.5375,
          "maximum": 48.9368,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 45.7191,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2-0      X977H",
      "code_information": [
        {
          "code": "3089325",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.8616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN GUT 5-0     1915G",
      "code_information": [
        {
          "code": "3089326",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 107,
          "minimum": 36.5795,
          "maximum": 167.9422,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 77.6499,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 3-0           Z774D",
      "code_information": [
        {
          "code": "3089328",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 7.7854,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 219.1614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 10-0      9003G",
      "code_information": [
        {
          "code": "3089335",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 259,
          "minimum": 7.7854,
          "maximum": 187.9563,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 187.9563,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0        793G",
      "code_information": [
        {
          "code": "3089348",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 192,
          "minimum": 37.8148,
          "maximum": 139.3344,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 139.3344,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 4-0 699G",
      "code_information": [
        {
          "code": "3089354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 68,
          "minimum": 23.2468,
          "maximum": 49.3476,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 49.3476,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON/MONO    ETH562H",
      "code_information": [
        {
          "code": "3089357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 7.7854,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0 CT1  J-945-H",
      "code_information": [
        {
          "code": "3089362",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 10,
          "minimum": 3.4186,
          "maximum": 33.366,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 7.257,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHILON 2-0        585H",
      "code_information": [
        {
          "code": "3089363",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.9319,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-SILK 2-0          C0125",
      "code_information": [
        {
          "code": "3089364",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 79,
          "minimum": 27.0073,
          "maximum": 179.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 57.3303,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXMD2B413",
      "code_information": [
        {
          "code": "3089371",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 322,
          "minimum": 110.0805,
          "maximum": 233.6754,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 233.6754,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPD2B408",
      "code_information": [
        {
          "code": "3089372",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 343,
          "minimum": 34.4782,
          "maximum": 248.9151,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 248.9151,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 3-0       U204H",
      "code_information": [
        {
          "code": "3089379",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 62,
          "minimum": 21.1956,
          "maximum": 44.9934,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 44.9934,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 2-0        J428H",
      "code_information": [
        {
          "code": "3089381",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 46,
          "minimum": 15.7258,
          "maximum": 38.3709,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 33.3822,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 6/0 P-1    J489G",
      "code_information": [
        {
          "code": "3089382",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 69,
          "minimum": 23.5887,
          "maximum": 50.0733,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 50.0733,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VICRYL 7-0        J488G",
      "code_information": [
        {
          "code": "3089384",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 58,
          "minimum": 7.7854,
          "maximum": 42.0906,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 42.0906,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX     SXPP1A400",
      "code_information": [
        {
          "code": "3089386",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 370,
          "minimum": 99.5419,
          "maximum": 268.509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 268.509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-ETHIBOND 2.0 ALL PX83Hs",
      "code_information": [
        {
          "code": "3089390",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.1186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-CHROMIC 4-0       1654G",
      "code_information": [
        {
          "code": "3089394",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 7.7854,
          "maximum": 66.7644,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.7644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-NUROLON 4-0       C584D",
      "code_information": [
        {
          "code": "3089396",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 236,
          "minimum": 80.6801,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 171.2652,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPD2B413",
      "code_information": [
        {
          "code": "3089403",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 391,
          "minimum": 48.9368,
          "maximum": 283.7487,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 283.7487,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PDS 5-0 Z493G",
      "code_information": [
        {
          "code": "3089407",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 88,
          "minimum": 30.0841,
          "maximum": 63.8616,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.8616,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-PLAIN 4-0 1644G",
      "code_information": [
        {
          "code": "3089408",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 99,
          "minimum": 7.7854,
          "maximum": 71.8443,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.8443,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-MERSILENE RS23",
      "code_information": [
        {
          "code": "3089410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 127.8575,
          "maximum": 378.7041,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 271.4118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-VLOC PBT xxMM",
      "code_information": [
        {
          "code": "3089416",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 681,
          "minimum": 232.81,
          "maximum": 1362.445,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 494.2017,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SUTURE-STRATAFIX SXPP1B406",
      "code_information": [
        {
          "code": "3089420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 380,
          "minimum": 129.9086,
          "maximum": 275.766,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 275.766,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUN-BIOPSY MONOPTY 16GX20CM",
      "code_information": [
        {
          "code": "3089701",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 372,
          "minimum": 127.1737,
          "maximum": 1121.6537,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 269.9604,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-PROCISE EICA8875-01",
      "code_information": [
        {
          "code": "3090040",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2017,
          "minimum": 689.5414,
          "maximum": 1463.7369,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1463.7369,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND-TURBINATE RED EICA4845-01",
      "code_information": [
        {
          "code": "3090049",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2053,
          "minimum": 701.8486,
          "maximum": 1493.1285,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1489.8621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WAND,TOPAZ MICRO ACH4041-0",
      "code_information": [
        {
          "code": "3090061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2685,
          "minimum": 917.9071,
          "maximum": 1948.5045,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1948.5045,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE .045      WS-1106ST",
      "code_information": [
        {
          "code": "3090191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 269,
          "minimum": 91.9616,
          "maximum": 236.8986,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 195.2133,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER #2          AR-7200",
      "code_information": [
        {
          "code": "3091195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 261.9777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-FIBER 2-0         AR-7220",
      "code_information": [
        {
          "code": "3091196",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 361,
          "minimum": 123.4132,
          "maximum": 261.9777,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 261.9777,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE 2.5         310.243",
      "code_information": [
        {
          "code": "3091211",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 852,
          "minimum": 291.2689,
          "maximum": 618.2964,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 618.2964,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K 1.6MM AGK16150",
      "code_information": [
        {
          "code": "3091237",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 466,
          "minimum": 159.309,
          "maximum": 871.4087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 338.1762,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BIT-2.5MM DRILL XFO082501",
      "code_information": [
        {
          "code": "3091238",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1567,
          "minimum": 535.7022,
          "maximum": 1137.1719,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1137.1719,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE          1806-0080S",
      "code_information": [
        {
          "code": "3091250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1197,
          "minimum": 207.4253,
          "maximum": 868.6629,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 868.6629,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE ASNIS III 1.4X150MM",
      "code_information": [
        {
          "code": "3091317",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 363,
          "minimum": 124.0969,
          "maximum": 263.4291,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 263.4291,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K .054          WS-1406ST",
      "code_information": [
        {
          "code": "3091319",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 239,
          "minimum": 81.7057,
          "maximum": 497.7095,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 173.4423,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-K              0152-0218S",
      "code_information": [
        {
          "code": "3091346",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 881,
          "minimum": 99.5419,
          "maximum": 639.3417,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 639.3417,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 040-365",
      "code_information": [
        {
          "code": "3091419",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1510,
          "minimum": 198.5277,
          "maximum": 1095.807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1095.807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY PK 046-072",
      "code_information": [
        {
          "code": "3091422",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 357,
          "minimum": 122.0458,
          "maximum": 259.0749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 259.0749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-MYO STERNOTOMY    047-032",
      "code_information": [
        {
          "code": "3091425",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 295,
          "minimum": 100.8501,
          "maximum": 342.5576,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 214.0815,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-OLIVE TIP      03.211.410",
      "code_information": [
        {
          "code": "3091436",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 616,
          "minimum": 157.3763,
          "maximum": 447.0312,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 447.0312,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-CANN 5.0 310.63",
      "code_information": [
        {
          "code": "3091500",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3340,
          "minimum": 55.61,
          "maximum": 2423.838,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2423.838,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VACURETTE-DISP 21665",
      "code_information": [
        {
          "code": "3091501",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 100,
          "minimum": 34.1865,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 72.57,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALANT-PROGEL PGPS002",
      "code_information": [
        {
          "code": "3091508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 5641,
          "minimum": 494.929,
          "maximum": 4093.6737,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 4093.6737,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-INFLATION SEID",
      "code_information": [
        {
          "code": "3091510",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 890,
          "minimum": 304.2597,
          "maximum": 645.873,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 645.873,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BURR-RND M 2.5MM 03.000.007S",
      "code_information": [
        {
          "code": "3091511",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 792,
          "minimum": 105.659,
          "maximum": 574.7544,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 574.7544,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBING-1/2X3/32 /10 3610",
      "code_information": [
        {
          "code": "3091513",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 190,
          "minimum": 64.9543,
          "maximum": 645.076,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 137.883,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLUE-GUN CMS REVOLUTION",
      "code_information": [
        {
          "code": "3091516",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1029,
          "minimum": 351.7789,
          "maximum": 1269.0202,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 746.7453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT 5MM EB210",
      "code_information": [
        {
          "code": "3091517",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2282,
          "minimum": 780.1356,
          "maximum": 1656.0474,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1656.0474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-VOYANT FINE EB230",
      "code_information": [
        {
          "code": "3091518",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2953,
          "minimum": 313.6404,
          "maximum": 2142.9921,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2142.9921,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-GUIDE CANNU FLEX .042X12",
      "code_information": [
        {
          "code": "3091560",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 564,
          "minimum": 121.2298,
          "maximum": 409.2948,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 409.2948,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WIRE-TEMPORARY CARDIA  024-100",
      "code_information": [
        {
          "code": "3091561",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 158.2026,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 158.2026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRILL-2.8MM FIBULA ROD 80-0642",
      "code_information": [
        {
          "code": "3091572",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1306,
          "minimum": 446.4755,
          "maximum": 947.7642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 947.7642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRAP-FACIAL DENTAL 714-6IN-GEL",
      "code_information": [
        {
          "code": "3093187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 249,
          "minimum": 85.1244,
          "maximum": 522.734,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 180.6993,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "WRENCH-ACCESSORY       3550-02",
      "code_information": [
        {
          "code": "3093195",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 940,
          "minimum": 207.4253,
          "maximum": 682.158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 682.158,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ENDOBUTTON-CL ULTRA PAC 1.2",
      "code_information": [
        {
          "code": "3094000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 2461,
          "minimum": 841.3294,
          "maximum": 1785.9477,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1785.9477,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BLADE-SNAPFIT 15 DEG    400152",
      "code_information": [
        {
          "code": "3102750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 716,
          "minimum": 244.7752,
          "maximum": 519.6012,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 519.6012,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCL0316",
      "code_information": [
        {
          "code": "3115410",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 184.9489,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 392.6037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-V-LOC CLOSURE VLOCM1545",
      "code_information": [
        {
          "code": "3115420",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 541,
          "minimum": 184.9489,
          "maximum": 392.6037,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 392.6037,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA ARM        420279",
      "code_information": [
        {
          "code": "3115515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 502,
          "minimum": 171.6162,
          "maximum": 364.3014,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 364.3014,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-CAMERA HEAD       420273",
      "code_information": [
        {
          "code": "3115525",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 490,
          "minimum": 167.5138,
          "maximum": 355.593,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 355.593,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DRAPE-INSTRUMENT ARM    420015",
      "code_information": [
        {
          "code": "3115580",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 537,
          "minimum": 183.5814,
          "maximum": 389.7009,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 389.7009,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "OBTURATOR-8MM LONG XI   470358",
      "code_information": [
        {
          "code": "3155025",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 376,
          "minimum": 128.5412,
          "maximum": 272.8632,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 272.8632,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 5MM        400161",
      "code_information": [
        {
          "code": "3170005",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 254,
          "minimum": 86.8337,
          "maximum": 265.8158,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 184.3278,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA 8.5-13MM   420206",
      "code_information": [
        {
          "code": "3170007",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 478,
          "minimum": 124.5664,
          "maximum": 346.8846,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 346.8846,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA            400077",
      "code_information": [
        {
          "code": "3170010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 224,
          "minimum": 76.5777,
          "maximum": 174.6154,
          "payers_information": [
            {
              "payer_name": "Anthem",
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              "standard_charge_dollar": 162.5568,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-CANNULA ENDOWRIST XI",
      "code_information": [
        {
          "code": "3170020",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEAL-UNIVERSAL 5-8MM XI 570361",
      "code_information": [
        {
          "code": "3170050",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 282,
          "minimum": 96.4059,
          "maximum": 1866.8277,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 204.6474,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL s.I.e.    410322",
      "code_information": [
        {
          "code": "3170060",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 1147.6403,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2436.1749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SEALER-VESSEL XI        480322",
      "code_information": [
        {
          "code": "3170070",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 3357,
          "minimum": 170.1666,
          "maximum": 2436.1749,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 2436.1749,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-TUB. & FILTER 20400162S/10",
      "code_information": [
        {
          "code": "3171250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 306,
          "minimum": 104.6106,
          "maximum": 222.0642,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 222.0642,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHEATH-ENDOWRIST STAPLER 45",
      "code_information": [
        {
          "code": "3171320",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 6652.0682,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SHUNT-NPH LOW FLOW      909506",
      "code_information": [
        {
          "code": "3171350",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 11962,
          "minimum": 976.5116,
          "maximum": 8680.8234,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 8680.8234,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TROCAR-BLUNT TIP 12M OMS-T12BT",
      "code_information": [
        {
          "code": "3175750",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1756,
          "minimum": 600.3147,
          "maximum": 1274.3292,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1274.3292,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PORT-SINGLE SITE 8.5    428065",
      "code_information": [
        {
          "code": "3185345",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1488,
          "minimum": 508.6949,
          "maximum": 1866.2716,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1079.8416,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-FLEXIBLE         3100A",
      "code_information": [
        {
          "code": "3240013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1449,
          "minimum": 201.3082,
          "maximum": 1051.5393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1051.5393,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-GENERATOR INFANT LP FLOW",
      "code_information": [
        {
          "code": "3240072",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 596,
          "minimum": 203.7515,
          "maximum": 432.5172,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 432.5172,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-INFANT O2 DELIVERY   RT329",
      "code_information": [
        {
          "code": "3240073",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 476,
          "minimum": 62.2832,
          "maximum": 345.4332,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 345.4332,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-RESUS S/USE       900RD010",
      "code_information": [
        {
          "code": "3240075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 112,
          "minimum": 38.2889,
          "maximum": 433.758,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 81.2784,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-EEG HYDROGEL",
      "code_information": [
        {
          "code": "3240083",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 207.9814,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.1186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODES-EEG LOW IMPEDENCE",
      "code_information": [
        {
          "code": "3240085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 374,
          "minimum": 72.8491,
          "maximum": 271.4118,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 271.4118,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "INTERFACE-TRACHEOSTOMY HI FLOW",
      "code_information": [
        {
          "code": "3240105",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 327,
          "minimum": 111.7898,
          "maximum": 273.0451,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 237.3039,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-BELLOWS & WATER TRAP 3100A",
      "code_information": [
        {
          "code": "3240167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 177.3959,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 650.2272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SET-CONNECTING TUBING.   3100",
      "code_information": [
        {
          "code": "3240170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 319,
          "minimum": 109.0549,
          "maximum": 245.7962,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 231.4983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 6 FR    196",
      "code_information": [
        {
          "code": "3249995",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 135.7059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE \\\"Y\\\" 8 FR    198",
      "code_information": [
        {
          "code": "3249997",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 187,
          "minimum": 63.9287,
          "maximum": 135.7059,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 135.7059,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE MAC 5FR    1925",
      "code_information": [
        {
          "code": "3249998",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 191,
          "minimum": 65.2962,
          "maximum": 138.6087,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 138.6087,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-TRACH CARE 14FR 12\\\" 220135",
      "code_information": [
        {
          "code": "3250000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 122,
          "minimum": 41.7075,
          "maximum": 232.4498,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 88.5354,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-TRACH SHILEY XLT UNCUFFED",
      "code_information": [
        {
          "code": "3281990",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 896,
          "minimum": 47.8246,
          "maximum": 650.2272,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 650.2272,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER DISP",
      "code_information": [
        {
          "code": "3282370",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 62.4102,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.4102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XS      006950",
      "code_information": [
        {
          "code": "3283013",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 196.8594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.5288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-PEP THERAPY  \\\"ACAPELLA\\\"",
      "code_information": [
        {
          "code": "3283015",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 354,
          "minimum": 111.22,
          "maximum": 256.8978,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 256.8978,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION  LG     006965",
      "code_information": [
        {
          "code": "3283017",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 145.14,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "DEVICE-FIXATION XLG     006970",
      "code_information": [
        {
          "code": "3283018",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 200,
          "minimum": 68.373,
          "maximum": 145.14,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 145.14,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUVETTE-CO2 DISP ADULT MP01062",
      "code_information": [
        {
          "code": "3284354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 198,
          "minimum": 53.9417,
          "maximum": 143.6886,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 143.6886,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-SHILEY XLT INNER 5MM",
      "code_information": [
        {
          "code": "3290045",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 176.8398,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.4102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL MED HIGH FLOW",
      "code_information": [
        {
          "code": "3290046",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 318,
          "minimum": 108.713,
          "maximum": 230.7726,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 230.7726,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL SM HIGH FLOW",
      "code_information": [
        {
          "code": "3290047",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 200.2932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CANNULA-NASAL LG HIGH FLOW",
      "code_information": [
        {
          "code": "3290048",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 276,
          "minimum": 94.3547,
          "maximum": 200.2932,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 200.2932,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT L599-130",
      "code_information": [
        {
          "code": "3290061",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 164,
          "minimum": 56.0658,
          "maximum": 205.757,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 119.0148,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-VENT W/MR290 SINGLE",
      "code_information": [
        {
          "code": "3290062",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 370,
          "minimum": 126.49,
          "maximum": 268.509,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 268.509,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-INFANT DUAL FLOW RT26",
      "code_information": [
        {
          "code": "3290077",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 442,
          "minimum": 82.3028,
          "maximum": 320.7594,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 320.7594,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CUSHION-CPAP NASAL NSC-001",
      "code_information": [
        {
          "code": "3290082",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 933.1358,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.4382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FLOW-CONT CYSTO GREENLYT",
      "code_information": [
        {
          "code": "3290084",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 1678,
          "minimum": 102.3224,
          "maximum": 1217.7246,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 1217.7246,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP MED",
      "code_information": [
        {
          "code": "3290127",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 133.5288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.5288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HEADGEAR-INFANT FLOW LP SMALL",
      "code_information": [
        {
          "code": "3290128",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 184,
          "minimum": 62.9031,
          "maximum": 133.5288,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 133.5288,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HOSE-AIR MODEL 205 DISP",
      "code_information": [
        {
          "code": "3290145",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 115,
          "minimum": 39.3145,
          "maximum": 174.0593,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 83.4555,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED SM NIV",
      "code_information": [
        {
          "code": "3290170",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.1441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED MED NIV",
      "code_information": [
        {
          "code": "3290171",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 107.0037,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.1441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL NON-VENTED LG NIV",
      "code_information": [
        {
          "code": "3290172",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 313,
          "minimum": 56.7222,
          "maximum": 227.1441,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.1441,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 42MM    RD804-10",
      "code_information": [
        {
          "code": "3290178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 102,
          "minimum": 34.8702,
          "maximum": 207.4253,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 74.0214,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CIRCUIT-BIPAP AIRLIFE W/FILTER",
      "code_information": [
        {
          "code": "3290184",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 114,
          "minimum": 38.9726,
          "maximum": 171.8349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.7298,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL XS INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290186",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 309,
          "minimum": 105.6362,
          "maximum": 224.2413,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 224.2413,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL LG INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290187",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 314,
          "minimum": 107.3456,
          "maximum": 227.8698,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 227.8698,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL MED INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290188",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 285,
          "minimum": 97.4315,
          "maximum": 206.8245,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 206.8245,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL SM INFANT FLOW LP",
      "code_information": [
        {
          "code": "3290189",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 308,
          "minimum": 58.3905,
          "maximum": 223.5156,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 223.5156,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NEONATAL 60MM    RD806-10",
      "code_information": [
        {
          "code": "3290194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 105,
          "minimum": 35.8958,
          "maximum": 76.1985,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.1985,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED SMALL NIV",
      "code_information": [
        {
          "code": "3290215",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 194.4876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290216",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 302,
          "minimum": 103.2432,
          "maximum": 219.1614,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 219.1614,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-FULL VENTED LARGE NIV",
      "code_information": [
        {
          "code": "3290217",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 268,
          "minimum": 91.6198,
          "maximum": 194.4876,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 194.4876,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED MED NIV",
      "code_information": [
        {
          "code": "3290218",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 231,
          "minimum": 78.9708,
          "maximum": 167.6367,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 167.6367,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "MASK-NASAL VENTED LG NIV",
      "code_information": [
        {
          "code": "3290219",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 87.1755,
          "maximum": 391.4944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.0535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "NEBULIZER-MISTY FINITY  002534",
      "code_information": [
        {
          "code": "3290245",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 119,
          "minimum": 40.6819,
          "maximum": 422.636,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 86.3583,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "STOPPER-DECANNULATION SZ4",
      "code_information": [
        {
          "code": "3290354",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 760,
          "minimum": 194.635,
          "maximum": 551.532,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 551.532,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TIP-DIRECTIONAL BALLARD  22059",
      "code_information": [
        {
          "code": "3290385",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 45.8099,
          "maximum": 388.7139,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 97.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY XLT TRACH 5MM PROX",
      "code_information": [
        {
          "code": "3290400",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 699,
          "minimum": 238.9635,
          "maximum": 507.2643,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 507.2643,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TUBE-SHILEY SLT UNCUFF 5MM",
      "code_information": [
        {
          "code": "3290401",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 679,
          "minimum": 232.1262,
          "maximum": 492.7503,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 492.7503,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING WHITE    PMV005",
      "code_information": [
        {
          "code": "3290506",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 876,
          "minimum": 299.4736,
          "maximum": 635.7132,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 635.7132,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-SPEAKING PURPLE  PMV2001",
      "code_information": [
        {
          "code": "3290508",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 875,
          "minimum": 33.366,
          "maximum": 634.9875,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 634.9875,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP LPEEP",
      "code_information": [
        {
          "code": "3290509",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 43.542,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "VALVE-PEEP ADJ          2K8082",
      "code_information": [
        {
          "code": "3290515",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 265.2597,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.5247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRUSH-THERAPRESSURE     262895",
      "code_information": [
        {
          "code": "3300010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 51,
          "minimum": 17.4351,
          "maximum": 582.7928,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 37.0107,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SOFT GOODS FOR CPM UNIT",
      "code_information": [
        {
          "code": "3302945",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 325.8746,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 238.7553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BOOT-UNNA VARICEX S",
      "code_information": [
        {
          "code": "3310024",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 83,
          "minimum": 28.3748,
          "maximum": 60.2331,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 60.2331,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-ENDURA KIT         775410",
      "code_information": [
        {
          "code": "3310985",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 151,
          "minimum": 51.6216,
          "maximum": 109.5807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 109.5807,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BGE   A840235",
      "code_information": [
        {
          "code": "3310986",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 126,
          "minimum": 43.075,
          "maximum": 91.4382,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 91.4382,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX BLACK  554617",
      "code_information": [
        {
          "code": "3310987",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 53.6728,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.9349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "TAPE-KINESIO TEX RED   A840241",
      "code_information": [
        {
          "code": "3310989",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 124,
          "minimum": 42.3912,
          "maximum": 89.9868,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 89.9868,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 6CMX5CM",
      "code_information": [
        {
          "code": "3310991",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 81,
          "minimum": 27.6911,
          "maximum": 58.7817,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.7817,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 8CMX5CM",
      "code_information": [
        {
          "code": "3310992",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 98,
          "minimum": 33.5028,
          "maximum": 71.1186,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 71.1186,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-COMPRESSION 10CMX5M",
      "code_information": [
        {
          "code": "3310993",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 120,
          "minimum": 41.0238,
          "maximum": 87.084,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 87.084,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDL K 12CMX5M",
      "code_information": [
        {
          "code": "3311000",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 135,
          "minimum": 46.1518,
          "maximum": 100.098,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 97.9695,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-ROSIDAL 15CMX.4CMX2.5M",
      "code_information": [
        {
          "code": "3311010",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 180,
          "minimum": 61.5357,
          "maximum": 161.269,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 130.626,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ12 12CM",
      "code_information": [
        {
          "code": "3311075",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 290,
          "minimum": 84.5272,
          "maximum": 210.453,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 210.453,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-TUBULAR TG SZ7 7CM",
      "code_information": [
        {
          "code": "3311076",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 152,
          "minimum": 51.9635,
          "maximum": 110.3064,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 110.3064,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL SOFT",
      "code_information": [
        {
          "code": "3311078",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 86,
          "minimum": 29.4004,
          "maximum": 126.2347,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 62.4102,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING C",
      "code_information": [
        {
          "code": "3311085",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 227,
          "minimum": 77.6033,
          "maximum": 164.7339,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 164.7339,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "AID-\\\"CLEAN EASY\\\" GRIP REACH",
      "code_information": [
        {
          "code": "3311086",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 280,
          "minimum": 95.7222,
          "maximum": 203.196,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 203.196,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXTENSION-FINGER ACU-SPRING D",
      "code_information": [
        {
          "code": "3311094",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 218,
          "minimum": 74.5265,
          "maximum": 391.4944,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 158.2026,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 10CMX5M RL",
      "code_information": [
        {
          "code": "3311107",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 29.4733,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SPONGE-LG HDL      C6298-01-25",
      "code_information": [
        {
          "code": "3311117",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 53,
          "minimum": 18.1188,
          "maximum": 83.415,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 38.4621,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE ADLT",
      "code_information": [
        {
          "code": "3311123",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 51.1612,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 6CMX5M",
      "code_information": [
        {
          "code": "3311138",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 92,
          "minimum": 31.4516,
          "maximum": 74.5174,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 66.7644,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-DURELAST 8CMX5M RL",
      "code_information": [
        {
          "code": "3311139",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 134,
          "minimum": 44.488,
          "maximum": 97.2438,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 97.2438,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-IONTOPHOR IOGEL 2971",
      "code_information": [
        {
          "code": "3311144",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 80,
          "minimum": 27.3492,
          "maximum": 58.3905,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 58.056,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-HYBRESIS PATCH",
      "code_information": [
        {
          "code": "3311150",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 106,
          "minimum": 33.366,
          "maximum": 76.9242,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 76.9242,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALU 1.5X3.5 PK 2393",
      "code_information": [
        {
          "code": "3311153",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 60,
          "minimum": 20.5119,
          "maximum": 86.1955,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 43.542,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-ALUM LTX FREE ALL",
      "code_information": [
        {
          "code": "3311156",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 155,
          "minimum": 52.9891,
          "maximum": 112.4835,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 112.4835,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "EXERCISER-POWER GRIP HAND",
      "code_information": [
        {
          "code": "3311157",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 63.5869,
          "maximum": 402.0603,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 134.9802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BRACE-COMFY HAND/THUMB",
      "code_information": [
        {
          "code": "3311158",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 723,
          "minimum": 28.3611,
          "maximum": 524.6811,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 524.6811,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-APPLICATION ELECTRODE PED",
      "code_information": [
        {
          "code": "3311161",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 150,
          "minimum": 37.2587,
          "maximum": 108.855,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 108.855,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUTRODE RND 1.25\\\"",
      "code_information": [
        {
          "code": "3311163",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 67,
          "minimum": 22.9049,
          "maximum": 48.6219,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 48.6219,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT OVAL PK 2\\\"X4\\\"",
      "code_information": [
        {
          "code": "3311164",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 74,
          "minimum": 25.298,
          "maximum": 62.8393,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 53.7018,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "FORK-WEIGHTED EZ GRIP 920675",
      "code_information": [
        {
          "code": "3311165",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 113,
          "minimum": 38.6307,
          "maximum": 91.7565,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 82.0041,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-ELECTRODE ADULT       9050",
      "code_information": [
        {
          "code": "3311167",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 165,
          "minimum": 56.4077,
          "maximum": 141.8055,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 119.7405,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "CRUTCH-BARIATRIC PR 550LB REG",
      "code_information": [
        {
          "code": "3311174",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 255,
          "minimum": 36.7026,
          "maximum": 185.0535,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 185.0535,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "ELECTRODE-VALUT SQ PK  1.5X3.5",
      "code_information": [
        {
          "code": "3311178",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 66,
          "minimum": 22.5631,
          "maximum": 293.0647,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 47.8962,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT M&LGE",
      "code_information": [
        {
          "code": "3311191",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 48.3807,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GUARD-FOOD INVISIBLE      1115",
      "code_information": [
        {
          "code": "3311192",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 87,
          "minimum": 29.7422,
          "maximum": 87.3077,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 63.1359,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-TRACTION EXER ALL C5032s",
      "code_information": [
        {
          "code": "3311193",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 157,
          "minimum": 35.5904,
          "maximum": 113.9349,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 113.9349,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "GLOVE-COMPRESSION RT&LT S&XS",
      "code_information": [
        {
          "code": "3311194",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 64,
          "minimum": 21.8794,
          "maximum": 280.2744,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 46.4448,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "HANDPIECE-LAVAGE    0210112000",
      "code_information": [
        {
          "code": "3311197",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 504,
          "minimum": 172.2999,
          "maximum": 365.7528,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 365.7528,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-CPM SOFTGOOD FOR HOME UNIT",
      "code_information": [
        {
          "code": "3311235",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 329,
          "minimum": 112.4735,
          "maximum": 238.7553,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 238.7553,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH LOWER EXTREMITY",
      "code_information": [
        {
          "code": "3311250",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 319,
          "minimum": 104.5468,
          "maximum": 231.4983,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 231.4983,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-HIP/KNEE W/26 REACHER",
      "code_information": [
        {
          "code": "3311251",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 188,
          "minimum": 64.2706,
          "maximum": 136.4316,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 136.4316,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "KIT-LYMPH UPPER EXTREMITY",
      "code_information": [
        {
          "code": "3311255",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 186,
          "minimum": 28.9172,
          "maximum": 134.9802,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 134.9802,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "PAD-ELASTO-GEL CAST/SPL  A8273",
      "code_information": [
        {
          "code": "3311340",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 52,
          "minimum": 17.777,
          "maximum": 65.0637,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 37.7364,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "BANDAGE-PADDING ROSIDAL 12CM",
      "code_information": [
        {
          "code": "3311347",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 117,
          "minimum": 39.9982,
          "maximum": 99.5419,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 84.9069,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "SALINE-WOUND WASH 210ML",
      "code_information": [
        {
          "code": "3311357",
          "type": "LOCAL"
        },
        {
          "code": "0270",
          "type": "RC"
        }
      ],
      "standard_charges": [
        {
          "setting": "inpatient",
          "gross_charge": 71,
          "minimum": 24.2724,
          "maximum": 87.8638,
          "payers_information": [
            {
              "payer_name": "Anthem",
              "plan_name": "Blue Traditional, Blue Access and Blue Preferred",
              "standard_charge_dollar": 51.5247,
              "count": "0",
              "methodology": "percent of total billed charges",
              "additional_payer_notes": "No services performed during 15-month lookback period."
            }
          ]
        }
      ],
      "service_type": "CDM"
    },
    {
      "description": "RING-D WRIST BRACE ALL SIZES",
      "